April 2014

PRACTITIONER

THE BUSINESS MAGAZINE FOR DOCTORS WITH A PRIVATE PRACTICE

In this issue

Working with a PA Get the best out of the crucial relationship on which the success of your practice hinges P22

Smoke and mirrors of SEO Ignore the trickery of search engine optimisation and turn website visitors into payers P27

New subscribers: Get your first 3 issues free – and £15 off –when you take out a subscription by direct debit this month  See page 24

New horizons clouded?

The common questions asked by doctors starting out in private practice P46

Sell-off shock for HCA

By Robin Stride

Consultants, staff and management at HCA’s The Wellington and new £33m Platinum Medical Centre have expressed indignation after the competition body gave the company a ‘ Sophie’s Choice’ ultimatum.

In its long-awaited final report, the private healthcare market inquiry group ruled that HCA bosses should choose between sacrificing the London Bridge and Princess Grace hospitals or selling off the UK’s largest private hospital (The Wellington) plus its flagship diagnostic and outpatient centre instead.

The first two were already under threat of a forced sale by the

Competition and Markets Authority (CMA) – formerly the Competition Commission. But the sudden addition of the St John’s Wood hospitals came as a complete shock.

And that soon turned to disbelief when it was learned that BMI, the largest hospital group, had pulled off a great escape by not having to sell seven of its hospitals after all.

HCA vowed to fight the decision all the way through the courts, saying it was confident it would win. It declared business as usual – including £120m of planned developments over the next two years, which will see London Bridge expand into London’s landmark building The Shard.

COMPETITION ‘REMEDIES’

 INCENTIVES/BENEFITS BAN: Restricting/banning incentive schemes and some benefits for consultants from private hospitals, especially those ‘likely to have the greatest influence on clinicians advising patients’. Greater transparency is key

 FEE DISClOSURE: New measures to give patients clearer information on consultants’ fees

 PERFORMANCE: Better data on consultants’ and private hospitals’ performance and outcomes

 FORCED SAlES: Divesture of HCA’s london Bridge and Princess Grace hospitals, OR The Wellington including its Platinum Medical Centre. BMI escapes threatened sell-off of seven hospitals

 WATCHDOG FOR PRIVATE PATIENTS UNITS (PPU): Measures to ensure arrangements between NHS trusts and private hospital operators to run/ manage a PPU to be reviewed by the CMA. It could ban some deemed to lessen local competition

Company president and chief executive Michael Neeb fumed: ‘HCA legally acquired these hospitals, in the case of the London Bridge with explicit approval by the OFT, yet now after millions of pounds of investment, it is being forced to sell.

‘The CMA’s main allegation appears to be that HCA is too successful, too efficient, too innovative. It wants to punish HCA for that success.

‘The proposed remedy sends a very disturbing signal to the market; this can only discourage future investment and innovation in healthcare, and potentially other industries, while it reduces patient access to top-quality care.’

Most of the final report’s other ‘remedies’ (see box) were as expected and they brought mixed reactions from those affected.

Federation of Independent Practitioner Organisations’ deputy chairman Mr Chris Khoo said: ‘We are entirely supportive of the authority’s desire to remedy

adverse effects on competition. In particular, we welcome the restriction on clinician incentive schemes that encourage patient referrals to particular facilities, and we agree with – and indeed have advocated for some time –the provision of fee estimates to patients and the availability of quality outcomes.’

Bupa Health Funding managing director Dr Damien Marmion welcomed the report, saying there were ‘some great features in it’ such as the improvement in transparency and the banning of incentive schemes.

It could spur the take-up of PMI and self-pay and the whole sector needed to get together to consider private healthcare’s future.

He added: ‘If we just focus on the thing that got us to here, we won’t advance any further. We need to think about what is in the customers’ interest to drive us forward. In that, I particularly focus on quality and value for money.’

 See pages 8-11 and 33

The future of Harley Street

Marketing experts are developing two imaginative new initiatives to promote the ‘Harley Street’ and the ‘London’ brand to overseas patients who would consider travelling for medical treatment.

Ideas to promote London aggres-

sively as a world centre of private care were thrashed out at a summit on ‘the future of Harley Street’ attended by many of the big players in private practice.

➱ Turn to full story on page 3 ➱ See special report on p12

April 2014

www.independent-practitioner-today.co.uk

look ahead to use your tax breaks

don’t wait ‘til the end of this new tax year. Make plans now to utilise allowances P18

ensure success of your group practice

Follow these basic guidelines to help make your partnership a successful one P30

destroying your data for good

We explain why and how it’s so important to dispose of It equipment safely P34

a complex code to crack

An examination of the complexities of coding shows why billing is so hard P36

The threat of a ‘mansion tax’ our financial adviser explains why your home could fall victim to a ‘weath tax’ P38

avoid the tribulations of tribunals

Smart advice on how private practitioners can stay out of the employment courts P40

Plus our regular columns

Business Dilemmas: ethical

ediTorial commenT

Big issues that will run and run

Now we are 60 issues old, we inevitably come across ‘new’ stories that bear a striking resemblance to ones that have done the rounds before.

Take the competition inquiry’s final report and the market’s reaction (see p1 and p8-11).

Much of this may sound familiar to private doctors, as it reiterates what we have already reported over many issues going back some years. But we suspect there will yet be some surprises in store regarding what happens next.

Then there’s the Harley Street initiative. We’ve been down this road before.

But this time we believe there could be some real progress in raising the enclave’s profile –and London’s – to the tens of thousands of potential patients around the world who have never heard of it and would travel. If only they knew you.

This big coming together in the capital reflects what we now see in NHS primary care where more and more GP practices are forming businessboosting federations.

Private clinic clusters must now surely have huge branding potential not only centrally but in other UK towns and cities too.

Tell us your news Editorial director Robin Stride at robin@ip-today.co.uk

Phone: 07909 997340 @robinstride

To adverTise Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094

To subscribe lisa@marketingcentre.co.uk Phone 01752 312140

Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897

Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe Circulation figures verified by the Audit Bureau of Circulations

Taxman gains power to drain bank accounts

by charles King

Doctor taxpayers’ bank accounts could be drained without prior notice under HM Revenue and Customs’ new powers to recover unpaid tax unveiled in the Budget.

HMRC has battled against slow or non-payers for many years, with processes to recover unpaid tax being very lengthy and costly for the public purse.

Doctors owing large amounts of tax would previously be chased by HMRC debt recovery officers, and if officials were unsuccessful, they would then have to commence proceedings in court and obtain an order before being able to seize a taxpayer’s assets or cash.

But the taxman has now adopted policies similar to some payday lenders in reserving the right to drain bank accounts without warning.

A spokeswoman for accountants Stanbridge Associates said this would only happen with debts over £1,000 where officials

had asked the taxpayer to settle the debt ‘multiple times’.

She said: ‘One would hope that this action will not come as a shock to anyone. HMRC also says it will leave a minimum of £5,000 across the taxpayer’s bank accounts after having taken the debt. This is to bring HMRC in line with other nations’ tax authorities such as France and the US.

‘Once the money has been taken, the taxpayer will have 14 days to contact HMRC and set up a payment plan. If they don’t, then the money taken will be kept by HMRC.’

Accountants hope there will be proper protections in place for situations where tax debts are deemed due by HMRC but are under dispute by the taxpayer.

The spokesman added: ‘Of particular interest is the fact that, in cases of bankruptcy, HMRC is not seen as a preferential debtor, so will HMRC be required to repay seized cash in the event of a subsequent bankruptcy order?’

ISAs now nisa than pension

The Chancellor’s surprising decision to raise the annual ISA limit from £11,880 to £15,000 from July 2014 will allow doctors to shelter more of their income tax-free.

Advisers say after recent press speculation of a cap on the overall size of ISA pots, this announcement confirms ISAs’ ongoing attraction to investors.

As an example, if a husband and wife invested £30,000 a year annually for the next 15 years and achieved a 3% real return, after charges and inflation, the final fund would be worth £668,222 from which tax-free withdrawals can be taken without restriction to supplement the NHS Pension.

The new ISA, or ‘NISA’, will also allow savers to enjoy more flexibility and move money from existing cash ISAs into investments and back again – a useful addition where circumstances change.

Patrick Convey, of specialist financial planners Cavendish Medical, said: ‘Even after the welcome proposed changes to pension savings, the fact remains that independent practitioners will not wish to maximise pension savings because of the Annual and Lifetime Allowance caps, whereas ISA legislation has remained generally free of restrictions.’

 See page 18

Plan to boost Harley St

➱ continued from front page

by robin stride

Organisers of the Harley Street summit on the enclave’s future last month have revealed an eightpoint battle plan.

It is hoped this will help combat growing overseas competition around the world, which is hijacking thousands of potential patients who might otherwise come to see consultants in the UK.

Intuition Communication, the organisers of the lock-out event with over 200 delegates, plans:

1. A ‘Harley Street Partnership’, which would maximise the impact of the brand, with the support of Harley Street consultants and clin-

escaped from the dragons’ den

ics. The intention for this would be to ‘crowdfund’ the initiative. It will invite individual consultants and clinics to commit to an upfront ‘membership’. This will enable it to fund:

2. A Harley Street Medical Advisory Service for people to act as a first point of contact for anyone considering use of Harley’s Street’s expertise. It could offer appointment making, a second opinion service and a concierge service.

3. A revamped HarleyStreet.com website which will enable access to the Harley St community and will focus on the knowledge and expertise of the medical community.

4. A Harley Street Media Panel, supported by a PR agency.

The doctor entrepreneur behind an online health & beauty price comparison site missed out on a £100,000 investment from the dragons’ den after the panel failed to see potential in the site that targets a £5bn market. Treatmentsaver.com, which helps people to find out prices, evaluate different clinics, book appointments online and save money, was unable to convince the bbc2 show’s business panel to part with their cash.

The brainchild of dr ganesh rao and optometrist Tim Harwood (pictured above), the website was the uK’s first to launch online appointment booking for the health and beauty sector.

5. A London Healthcare marketing initiative which would strengthen London’s presence in the international markets with the support of a wider range of private healthcare providers. This could include:

6. A London Healthcare Destination Guide (in print and online) aimed at the international medical travel community.

7. A co-ordinated London presence at international events.

8. A London medical travel conference focusing on what London has to offer internationally.

Intuition’s managing director Keith Pollard told Independent Practitioner Today : ‘What we are able to achieve within the Harley Street Partnership will depend

whether we can secure financial commitment from the consultant and clinic community.’

He said the London Healthcare project would have a wider remit and a broader basis for funding.

To take the Harley Street Partnership initiative forward, organisers need to seek input and involvement from a small group of interested parties who would form a steering committee.

Several expressions of interest had been received from attendees as Independent Practitioner Today went to press. An evening discussion forum ‘Shaping the Future of Harley Street’ was being planned to get the ball rolling.

See report on summit, p12-14

King Edward VII’s new boss seeks consultants’ views

The new chief executive of King Edward VII’s Hospital has said he looks forward to forging strong relationships to help consultants develop their practices.

Mr Andrew Robertson ( right ) said: ‘We need to grow our business, market our services to the outside world a lot more than perhaps we do, and work with doctors as to how we can do that.

‘I am interested in knowing how they feel we can do that together.’

Mr Robertson has managed vari-

ous private hospitals over the last 25 years including the Priory Hospitals Group in Southampton, St Martin’s Healthcare (Devonshire Hospital W1), three BMI hospitals and latterly Ashtead Hospital, Surrey, for Ramsay Health Care. Hospital president HRH the Duke of Kent has meanwhile officially re-opened a bigger outpatients unit at Emmanuel Kaye House, London, now offering 11 consulting rooms and space for seven medical secretaries.

Big rise in help sought on disclosing notes

A 65% rise in the number of doctors seeking advice about disclosing medical records to third parties is being reported by defence body MDDUS.

Common requests include fathers without parental responsibility wanting access to their child’s medical records, police seeking records for a criminal case or relatives requesting a patient’s records after death.

The Data Protection Act 1998

allows patients to access their medical records, but information relating to some third parties cannot be disclosed without their consent.

Union medical adviser Dr Naeem Nazem said: ‘When a patient requests access to their own records, doctors should remove identifiable third-party information, other than from other healthcare professionals acting in that capacity. The exception to this position is if the third party

provides their consent to the disclosure.

‘Likewise, if the record contains personal sensitive data which is likely to cause serious physical or psychological harm to either the patient or third party, this should be removed if appropriate.’

The MDDUS said according to the Information Commissioner’s Office (ICO), third-party information can be disclosed under the Data Protection Act when consent

has been attained or when ‘it is reasonable in all the circumstances to comply with the request without the individual’s consent’.

The ICO also states the decision to disclose will ‘involve balancing the data subject’s right of access against all the other individual’s rights in respect of their own personal data. If there is no consent, you must decide whether to disclose the information’.

 See ‘Business Dilemmas’, p44

Expert advice on annuity flexibility

By Leslie Berry

Retiring doctors will get the freedom to choose what to do with their own pension pots under big changes announced in the Budget.

The first 25% drawn will remain tax-free, but instead of turning the balance of pension savings into a guaranteed lifetime income in the form of an annuity, senior doctors aged over 55 will have complete access to their pension savings from April 2015.

Advisers say although this sounds very attractive, in reality it is likely to be of greater benefit to doctors’ spouses where their

pension funding has been made from partnership earnings or limited company profits and where their marginal income tax rate is likely to be much lower in retirement than their higher-earning partner.

Doctors drawing NHS pensions have already had more access to their personal pension pots than the general public due to qualification for the ‘minimum income requirement’ for access to flexible drawdown.

But the Chancellor’s announcement to lower the minimum qualification limit for income from £20,000 to £12,000 in the period

prior to April 2015 will help those with less valuable NHS Pension benefits.

Cavendish Medical managing director Simon Bruce said: ‘It’s refreshing to finally receive some good news on pensions.

‘Instead of encouraging independent practitioners to strip funds out of their personal pension or SIPP in retirement, the proposed reduction of the 55% tax on death makes it much more attractive to keep pension funds invested and to pass these on to family members in future.’

The proposals are subject to consultation.

Seniors reject 7-day week

A consultants’ leader has warned that it is unrealistic to expect their current numbers to support sevenday services in the NHS as well as all their existing activity.

BMA’s Consultants Committee chair Dr Paul Flynn said consultant burnout was in nobody’s interest and significant manpower expansion would be needed if the health service wanted to provide services every day.

He told the consultants’ annual policy-making meeting held in London: ‘We are clear that the standard consultant contract must remain a ten-programmed activity contract – with any

additional hours being entirely voluntary.

‘Consultants must have job plans that allow them to maintain a proper work-life balance to enable them to continue to do the highly demanding job that they do, assuring the quality of patient care.’

Dr Flynn said his committee believed individual consultants’ interests would not be served by a local contract free-for-all.

As part of the contract negotiations, the BMA was considering if the current pay system should change. There had to be fairness and that should mean those who

contributed the most received the most and that the system recognised the changing contribution that came with experience.

The real-terms value of consultant pay for their NHS work was now lower than before the 2003 contract and had been outstripped by inflation.

Dr Flynn said no pay system should be able to pressurise consultants who highlighted inconvenient and uncomfortable truths to employers.

They had to be free to raise concerns without the fear of being punished by the withholding of pay.

BMA to audit gradual NHS privatisation

Consultants at the BMA consultants’ conference called on the BMA to monitor creeping NHS privatisation and publicise it.

Backing a motion by North-west London Regional Consultants Committee, they also expressed dismay that private providers had

won most tenders for service since the Health and Social Care Act started last April 2013. And they condemned ‘the huge amount of taxpayer money flowing into the profits of these private companies, rather than being used for patient care’.

Consultants Committee chairman Dr Paul Flynn claimed there were an increasing number of ‘worrying situations’ developing and there was no way some of the savings that providers talked of could possibly be made without impacting on patients.

Sale of good will is fast evaporating

Selling goodwill in medical practices is coming under the spotlight at a workshop next month for independent practitioners and their accountants.

The event on Wednesday 14 May at the Royal Society of Medicine, London, comes as some tax inspectors have been arguing that goodwill for professionals –including doctors, dentists, accountants and solicitors – does not exist, as it is entirely personal.

But this view is completely different to that held in many other developed areas of the world and in particular the US, where there is very active trading in medical practices, with sales of both free and personal goodwill.

The workshop aims to give practical guidance and comments on medical practice goodwill and on HM Revenue and Customs’ current thinking.

The speakers will be Mark Dietrich, a leading US-based medical accountant with extensive experience of valuations and litigations, and Vanessa Sanders, a director of medical accountants Stanbridge Associates Ltd, who has taken an active role in negotiations with HMRC on the subject.

Topics to be covered include:

 The current market in the UK for medical practice sales;

 The changing approach by HMRC to medical practice goodwill in the UK;

 The statute/case law relating to medical practice goodwill;

 Counsel’s current opinion and advice;

 The US market for medical practice sales;

 Methods of valuation commonly used in the US;

 The US tax authorities’ views on medical practice sales and treatment of taxation;

 US case law covering developments and definitions of ‘free’ and ‘personal’ goodwill.

The workshop costs £180 including VAT. Details from Maggie Stitt, Stanbridge Associates Ltd. Phone 01522 546606. Email mstitt@stanbridgeaccountants.co.uk

Appeal to join IDF ‘army’

By Robin Stride

Any independent practitioner seriously working in private practice should now join up to the growing ‘army’ of Independent Doctors Federation (IDF) members, according to the body’s newly-elected president and council chairman.

Private GP Dr Peter King-Lewis issued the challenge at the IDF’s annual general meeting in London after outgoing chairman Mr Ian Mackay announced a 4% membership growth last year to 1,177.

The meeting heard that 36% of members were working outside London, 32% were aged under 50, and more than a quarter of the total number now were GPs.

In an address to members, Dr King-Lewis said: ‘The IDF was, in its infancy, “exclusive” – for doctors in purely private practice. It is now “inclusive” and any doctor who has any significant private practice should be a member.

‘The larger the army, the louder the voice and anyone you know who practises privately and is not a member needs to be encouraged to join.’

He said his predecessors had each developed the IDF – celebrating its silver jubilee this year – in their various ways to make it the ‘strong organisation’ it now was.

Dr King-Lewis, of The KingLewis Family Practice, 2 Lower Sloane Street, London, said he aimed to build on the federation’s strengths.

He had called a strategic review meeting to look at what it stood for in relation to its various stakeholders and whether there were ways it could improve.

‘As president, I will be looking outwards to membership and to the wider world of medicine, politics, insurance and so on, while as chairman of council, taking care of the inner workings of the IDF and its vital structure of subcommittees through which the mem-

Watchdog has ‘let insurers off hook’

The IDF made representations to the Competition Commission in the run-up to its final report (see pages 1 and 8) over a major ‘sticking point’ concerning private medical insurers’ influence over fees, the meeting heard.

Dr Brian O’Connor, chairman of the federation’s specialists’ committee, said the group believed insurers ‘have got off lightly’.

He argued that insurers were constraining fees and the group regarded that as applying antimarket forces.

Addressing the AGM –held before the commission’s final report – he said the private healthcare inquiry had been the numberone issue on the agenda in the past year and specialists were disappointed with its preliminary report.

The IDF’s specialists’ committee had held ‘lots of useful constructive discussions’ with insurers over the last year, but had experienced resistance to its suggestions, he said.

Dr O’Connor expressed the hope that with Bupa posting bigger than ever profits, there might be more flexibility.

For the coming year, he said the committee had some new members and would expand its role. He added that he felt bullish and very positive about the future.

bers of council do so much essential work.’

He believed there were many professional advantages to becoming a member and said many of these were outlined in reports given to the meeting by subcommittee chairmen.

‘The IDF does a great many things and it is only by participation of the membership that we can continue “Promoting Excellence in the Independent Medical Sector”.’

Outgoing chairman Mr Mackay took over the role of the IDF’s Responsible Office (RO) from the organisation’s ‘founding father’ Dr Stuart Sanders, who has stood down. Mr Mackay praised him for doing a ‘magnificent job’.

Despite the rise in the IDF’s numbers, there is amazement within the membership that so many private doctors appear to still have never heard of it.

Mr Mackay said 27 events were arranged for IDF members over the next eight months, including a UK study weekend (May 9-10) in Bath. The IDF wanted to be UK-wide and he hoped there would be study weekends elsewhere in future.

IDF treasurer Dr Michael Craig said the membership increase was largely due to people joining for appraisal and revalidation reasons.

The IDF now had six members in its administration team and is looking at possibly renting premises in London.

Indemnity costs are a bar to private

‘Going private’ is just not economical for some doctors due to the cost of their indemnity, according to a medical defence boss.

Dr Christine Tomkins, chief executive of the MDU, told the IDF this was not in the interests of anybody: the doctors being asked to pay subscriptions to meet big claims, the public or patients.

The meeting heard one consultant in the audience was now pay-

practice

ing over £200,000 a year for cover. At the current rate of increase, doctors’ bills are set to get a whole lot worse over the next few years.

Dr Tomkins forecasted that the cost of claims will double by 2020.

 So what can be done? Read the MDU’s proposals in a future edition of Independent Practitioner Today and see how you can take part in the campaign to reform compensation laws.

A total of 422 doctors went through appraisal with the IDF’s 44 appraisers in the last year.

Dr Jack Edmonds, chairman of the federation’s appraisal committee, said of 265 who responded to

a survey, only 0.3% were negative about IDF appraisal and only 1.16% were negative about its role in the process. 80% regarded the appraisal process as useful in their professional development.

Dr Peter King-Lewis, a London GP

Dr Brian O’Connor

Independent doctors federatIon’s annual meetIng

Probe leads BMA event

By Edie Bourne

The BMA is offering independent practitioners the chance to network with leading figures in private healthcare when it runs its annual Private Practice Committee (PPC) conference.

Delegates are being asked to stay on at the end of the Thursday 1 May meeting at BMA House in London for a formal networking opportunity over drinks and canapés.

BMA private practice chairman Mr Derek Machin told Independent Practitioner Today the event was ‘an exciting opportunity’ to discuss and debate the outcome of the competition inquiry final report with leading experts.

All doctors in private practice would now be affected by it, he warned.

Delegates at the event will also be able to consider the future of

private practice more generally.

Nearly an hour will be devoted to the competition inquiry as three speakers give a providers’, insurers’ and doctors’ perspective on the future of private healthcare in the UK.

The BMA said speakers will be BMI Healthcare chief executive

Stephen Collier, Bupa Health Funding managing director Dr Damien Marmion and Federation of Independent Practitioner Organisations’ chairman Mr Geoffrey Glazer.

Doctors attending will also hear about ‘how not to get banged up in private practice’.

Matt James, chief executive of the Private Healthcare Information Network, will talk on data in the independent sector, another big issue examined by the competition panel.

The meeting will also hear about the future of cosmetic interven­

Doctor’s ‘candle’ novel rekindles friendships

Consultant and novelist Dr Quentin Smith has thanked Independent Practitioner Today for helping him rekindle friendships with lots of doctor readers he had lost touch with.

He heard back from a wide variety of old friends after we reported on (July/August 2013) the anaesthetist’s first mystery thriller The Secret Anatomy of Candles

Dr Smith, who works at the Spire Hospital, Washington, Tyne and Wear, said: ‘I received calls from long­lost colleagues all over the country as a result of that. Your publication is certainly read far and wide.’

But now, his phone is set to be buzzing again because his second novel, Huber’s Tattoo, has just hit the high street.

The book raises the question of whether the Nazi ambition to breed a super race in the 1930s was actually realised.

Set in London in 2011, several loosely connected murders are gradually traced back to the secretive and shocking Nazi eugenics programme centred around Himmler’s Lebensborn birthing homes.

As this bizarre pattern becomes more noticeable, the intellectually brilliant DCI Webber of Scotland Yard discovers that his own links to the Lebensborn programme, and the murders themselves, are much closer than he could have ever imagined.

A parallel narrative, starting in 1936, follows the Nazi medical doctors involved in this project to engineer Aryan super­intelligence. The two narratives eventually converge to create what Dr Smith describes as ‘a thrilling finish’.

 Huber’s Tattoo , by Quentin Smith, published by Matador, £9.99, ISBN 9781783063529.

Distributor: Orca Book Services.

tions in the independent sector in a talk from Mr Mark Henley, chair of the Independent and Aesthetic Committee, British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS).

For the afternoon, the conference splits into three streams – for specialists setting up in private practice, established private consultants and private GPs.

Talks include:

 Groups and chambers: advantages and disadvantages, led by Dr Sean Tighe, chairman of the Association of Anaesthetists’ Independent Practice Committee;

 Workplace pensions, the Bribery Act and tax, led by Dr John Canning;

 Basics about setting up in private practice, led by PPC chairman Mr Derek Machin;

 Medical indemnity, featuring a Medical Protection Society speaker;

win a free copy!

Subscribers signing up for Independent Practitioner Today using the form in this issue will be entered into a draw for a free copy of Huber’s Tattoo. Sign up on page 26 for our special offer of three free issues of Independent Practitioner Today plus a £15 discount plus a chance to win Dr Smith’s new novel. We have five signed copies to give away.

 The insurer and consultant relationship, led by Dr Annabel Bentley, medical director, Bupa Health Funding.

The private GPs’ stream, chaired by PPC deputy chairman Dr Susan Horsewood­Lee, includes:

 The new Care Quality Commission regime and the practicalities, led by Matthew Trainer, deputy chief inspector of primary care;

 Technological innovations to help your practice, with Harley Street GP Dr Justine Setchell.

The PPC said the conference was targeted at all doctors engaged wholly or partly in private practice, as well as those looking to set up, and was relevant to consultants, GPs, associate specialists and junior doctors.

Cost: £100 BMA members (£150 non­members). Details available by emailing confunit@bma.org.uk or by phoning BMA Conferences on 020 7383 6137.

Insurers warn about websites

The Association of Medical Insurers and Intermediaries (AMII) has written to the Financial Conduct Authority warning of the detrimental effect of unauthorised websites that sell on users’ data. It said these websites, operated by lead ­ generation companies, often imitate those of genuine health insurance brokers to capture leads, which are then sold on to authorised firms.

Outgoing AMII vice­chairman Brian Walters said: ‘We have found over 25 of these websites and there are doubtless others.

‘Although the small print usually makes clear that leads will be passed to an authorised intermediary, use of the first person such as “we work with all the top UK private medical insurers” misleads consumers into believing that the website is operated by a broker.’

The AMII complains these websites can damage the reputation of the industry and represent unfair competition.

HCA bags top prize in international market

HCA International has been named Specialist International Patient Centre of the Year at The International Medical Travel Journal annual awards.

The award was presented to Khadija Mouhajer, director of international business services, in recognition of the investment and high ­ quality service that attracts patients to HCA in London.

HCA International beat off competition from similar medical groups from around the world to clinch the award.

The awards took place at a reception in Dubai, United Arab Emirates, during the International Medical Travel Exhibition and

Conference which brings together all the pre­eminent providers and experts in medical travel and medical tourism.

HCA chief executive and president Mike Neeb said: ‘Some of the best doctors in the world choose to practise at HCA’s hospitals and many patients travel to London to access their skills.

‘HCA is often competing in a global healthcare market, facing alternatives in Germany, the United States and Singapore among others. Our hospital group strives to provide not only the best treatment and outcomes, but also the best overall service for patients, in the knowledge that it must maintain the highest stand­

ards and best quality of care every day of the year.’

Judging panel chairman Keith Pollard said: ‘All our winners exemplify the way the medical tourism industry should be run –professional, offering exceptional patient care and providing the best possible medical outcomes.’

See page 3 lead story

Spire buys top heart hospital

St Anthony’s hospital, Cheam, is to be bought by Spire Healthcare.

Chief executive Rob Roger said the 92­bed Surrey hospital would be a central platform for the group’s continued growth in cardiology and other areas of acute care.

Nuffield’s new medical head

Cardiff consultant orthopaedic surgeon Mr Geoff Graham has been appointed Nuffield Health hospitals’ medical director. He was involved in setting up Vale Healthcare – the collaboration between Nuffield Health and a group of consultants – which later rebranded as Nuffield Cardiff and Vale Hospitals.

Innovation law no threat

By a staff reporter

A defence body claims there is no need for new legislation that would affect doctor innovators.

Commenting on the draft Medical Innovation Bill, the Medical Defence Union’s Dr Michael Devlin said: ‘We are happy to reassure doctors that medical innovation should not leave them open to an increased threat of litigation.’

He said a written statement introducing the Medical Innovation (No 2) Bill stated that doctors

wishing to depart from established procedures and carry out an innovative treatment may be fearful of doing so because of the possibility of a clinical negligence claim.

But the MDU had seen no evidence to suggest this was the case.

Dr Devlin, head of professional standards and liaison, said: ‘We regularly advise all types of doctors about the risks and medicolegal implications of using an innovative treatment or experimental drug regime.

‘Our advice is that there should be no consequences, providing

there are appropriate safeguards in place, the patient fully understands what is proposed and why the clinician believes it is in their best interests, and they give their fully informed consent.

‘When considering innovative treatment for the patient’s benefit, doctors are also ethically required to explain how the proposed treatment differs from the usual methods, why it is being offered and if there are any additional risks or uncertainties.’

He said it was important for doctors to get appropriate ethical and

organisational approval and follow local procedures for doing so.

‘Doctors now practise in a climate where there are increasing numbers of guidelines on good practice, but for medicine to evolve and develop, there must be departure from accepted practice at times.

‘Legal and ethical requirements don’t present a barrier to such innovation so long as doctors can show they acted with reasonable care, had good reason to depart from established or standard practice and the patient has consented to the treatment proposed.’

New owner for practice software firm

Practice management system

MidexPro has a new owner to enable the software to take advantage of the latest technology.

Avebury Computing Ltd, the company behind it, has been bought by MidexPro customer support manager Gary Parker. Rodney and Jayne Howlett, who originally developed the software, are retiring but will be involved as

the software is re ­ engineered to enable it to take advantage of current technology.

Mr Howlett said: ‘MidexPro has proved over the years to be an extremely robust and easy to use software package. We believe its friendliness is what has made for such a devoted following among secretaries and consultants alike.’

Mr Parker said retaining the soft­

ware’s user­friendliness was a top priority.

‘Our objective over the next few months is to make the transformation of MidexPro as invisible as possible to existing users so they will be able to migrate to the newer, more powerful software while barely noticing the transformation.

‘Once migrated, we will be able

to take advantage of the very latest technology and expand the functionality. We will also be taking this opportunity to cater directly for the growing Mac community.’ A download will be available free online to users.

MidexPro was one of the very first practice management systems available when released in October 1993.

Khadija Mouhajer receives the trophy from Keith Pollard

Competition inquiry findings

Bid to boost competition

What the Competition

and Markets

Authority – formerly the Competition Commission – said in its report

Two years after launching its investigation, the final report of The Competition and Markets a uthority (CM a ) announced measures including:

 a crackdown on benefits and incentive schemes provided to referring clinicians by private hospital operators;

 Plans to increase available information to patients about consultant fees and the performance of specialists and private hospitals.

The CMa also requires HCa to sell the London Bridge and Princess Grace hospitals or alternatively The wellington hospital, including its Platinum Medical Centre. But there will be no enforced hospital sales outside central London.

Future arrangements where private hospital operators team up with NH s private patient units (PPUs) will be scrutinised and banned if any might substantially lessen competition.

The CM a said it found many private hospitals faced little local competition across the UK and there were high barriers to entry.

incentive schemes

This led to higher prices for selfpay patients in many areas – and for both self ­ pay and insured patients in central London, where HCa, which owns over half of the available overnight bed capacity, ‘charges significantly higher prices to insured patients than its closest competitor’.

Investigators also pointed the finger at incentive schemes which

Background to the inquiry

the competition and Markets authority (cMa), an independent public body, carries out investigations into mergers, markets and the regulated industries. it was formed at the beginning of this month (april) when the competition commission (cc) joined with the competition and certain consumer functions of the office of Fair trading (oFt).

the members of the private healthcare market investigation group are: its chairman and panel chairman roger Witcomb (pictured), Jayne almond, tony Morris, Jeremy Peat, and Jonathan Whiticar.

the oFt referred the market to the cc for investigation two years ago this month. under the enterprise act 2002, the oFt could make a market investigation reference to the cc if it had reasonable grounds for suspecting that competition for the supply or acquisition of certain goods or services is not working effectively.

encourage consultants to refer patients for treatment or tests to particular providers. It said these could lead to these referrals being driven by considerations other than quality and price.

The CMa said lack of available information on private hospital and consultants’ performance, and on specialists’ fees, meant patients found it hard to make informed choices which would drive competition between providers on quality and price.

Private Healthcare Inquiry Group chairman roger witcomb claimed: ‘These are measures which will bring changes across the country.

‘The sale of HCa hospitals will significantly increase competition in central London, in particular by allowing the insurers to offer corporates and individual policyholders a comprehensive alternative to HCa

‘ we’re also introducing measures which will improve competition across the whole market and ensure private patients get a better deal. Greater information on the performance of hospital operators and of consultants as well as consultants’ fees will allow patients to make far better informed choices about what they are paying for, when deciding which hospital and consultant to choose for their treatment.

‘ a more transparent market with patients actively making choices will drive hospital operators to compete on the things that matter to patients.

in its inquiry, the commission was required to decide if ‘any feature, or combination of features, of each relevant market prevents, restricts or distorts competition in connection with the supply or acquisition of any goods or services in the united kingdom or a part of the united kingdom’.

if so, then it was ruled that there was an adverse effect on competition and the cc had to consider if this was resulting in a detrimental effect on customers such as higher prices, lower quality or less choice of goods or services.

the cc was then tasked to decide if it should introduce remedies to tackle the adverse effect on competition or detrimental effect on customers or whether to recommend action be taken by other bodies to remedy the adverse effects on competition, and if so, what actions or remedies should be taken.

if the cc found no adverse effect on competition, then the question of remedies did not arise.

‘equally, we are going to restrict incentive schemes that encourage patient referrals to particular private hospitals – again so that the advice given by consultants is driven solely by the merits of individual facilities.

market power

‘we have found that many private hospitals face weak local competition and it is difficult for new hospitals to enter the market. For self ­ pay patients, for whom charges are set locally, this can lead to higher prices.

‘additionally, in central London it is clear that HCa’s market power allows it to charge higher prices to insurers, who need to include its hospitals if they are going to provide cover for patients in central London.

‘ o utside central London, the effect of weak local competition on prices charged nationally to insurers is less clear. The volume of evidence was huge and we car­

ried out a very detailed analysis, but it was ultimately not possible to extract a consistent picture from it.

‘Having considered the analysis carried out after provisional findings, two members of the Inquiry Group decided they could no longer be confident that local concentration outside central London had led to higher prices for insured patients – and so the Inquiry Group has not ordered the sale of hospitals outside central London.

‘ o pening up this market to greater competition is not easy because there are high barriers to entry. High costs and long lead times mean that new competing facilities are not going to spring up easily. what we have done is to tackle some of the other barriers which can prevent a new operator getting a foothold in a particular area and to focus on measures which will improve things for patients in all areas of the country.’

Reaction to private sector shake-up

Many implications in the report’s hundreds of pages are still being evaluated, but here are some of the interested parties’ initial reactions:

HCA

HC a accused the The Competition and Markets a uthority’s (CM a ) ruling of undermining quality healthcare in London and of ignoring a number of key points, claiming it would harm patients’ interests and punish healthcare innovation.

It said its hospitals were sold a decade ago because they were not considered viable. Now they were world­class centres, offering highquality, innovative cardiac and cancer care. around 98% of HCa International’s patients would recommend its hospitals to family and friends.

Company president and chief executive Mike Neeb said: ‘HCa Inter national made significant invest ments to transform these facilities into some of London’s leading hospitals. a s a result, patients now have greater access to higher­quality care than they had ten years ago, and they come to us because of that level of quality.

‘The CM a has treated the highly complex healthcare system as a commodity market, focusing almost exclusively on price and overlooking the importance of quality. By contrast, quality is every patient’s primary concern. we are the only private health provider in the UK to publish independently­assessed clinical results across cancer care, cardiac surgery, neurosurgery and intensive care.

‘In failing to consider our investment, the mix of patients we treat, and the complex procedures we carry, the CMa has drawn inaccurate conclusions about HC a International’s pricing – something which we strongly refute and will of course be challenging.

‘HC a legally acquired these hospitals – in the case of the London Bridge, with explicit approval by the o ffice of Fair Trading (oFT) – yet now after millions of pounds of investment, it is being forced to sell.

‘The CM a’s main allegation

appears to be that HCa is too successful, too efficient, too innovative. It wants to punish HCa for that success.

‘The proposed remedy sends a very disturbing signal to the market; this can only discourage future investment and innovation in healthcare, and potentially other industries, while it reduces patient access to top quality care.

‘Today, HCa International delivers world­class care through a tight network of hospitals – a model recognised the world over as the best way to deliver complex care to patients. Now, the CMa is proposing to break up that network, undermining HC a’s strategic investment in improving the quality of care available to patients.

‘The CM a has received and ignored hundreds of letters from senior and eminent clinicians, voicing their serious concerns about divestment.’

Dr s ean Preston, a consultant gastroenterologist, said the CMa’s findings were ‘a considerable concern to me and many other consultants’. ‘Having practised for many years at The Princess Grace Hospital, it is clear that HCa’s network means I have immediate access to world­class colleagues in first­class medical facilities, which has resulted in excellent clinical outcomes for my patients.’

HC a said by the CM a’s own admission, there were over 50 competing hospitals in London, and the market continues to expand and deliver new and innovative treatments that were driving up quality and saving patient lives.

Bupa

‘a step in the right direction’ is how Bupa viewed the overall report. It called on the sector to now work together and go further to drive better value for customers.

It thought the CM a’s conclusions went some way to address behaviour by hospital groups and consultants which was leading to higher prices for both insured and self­pay patients.

Bupa Health Funding managing director Dr Damien Marmion claimed the sale of key HC a London hospitals would help increase competition and have a positive impact on customers in central London.

But self ­ pay and insured customers would be surprised that no action was taken outside the capital ‘where excess profit and consumer detriment has been identified by the CM a , particularly as the majority of the CMa panel believed there was sufficient evidence to justify more significant intervention’.

Dr Marmion said the insurer was pleased at measures to end

consultant incentives schemes and require the publication of better information to patients on doctors’ outcomes and costs.

a nd he indicated Bupa was ready to fund its share of a new information body for the private sector ‘because it will increase transparency and help patients make more informed choices’.

Dr Marmion continued: ‘ we urge the sector to work together and to go further to revive the market to drive better value for customers and address significant customer detriment, particularly outside central London.

‘This is the only way to achieve a sustainable long­term future for the sector and deliver improved value and quality to many more people. Bupa will pass on any money saved from increased competition among hospital providers to our customers.’

The insurer emphasised that the CMa found that no insurer had enough buyer power to offset the market power of major hospital groups. ‘They previously stated that by working to keep premiums down and promote competition on price and quality, insurers like Bupa are doing “exactly what their customers would expect”.’

It added that the CMa conservatively estimated the potential extra cost to customers caused by ‘excessive profits’ of the largest three hospital groups was between £155m ­ £174m a year between 2009 and 2011.

The report did not highlight competition concerns among insurers, including Bupa.

Saving grace: either the Princess grace or the Wellington faces the boot

the Platinum Medical centre at the threatened Wellington hospital, London

private-sector adviser

Keith Pollard, chief executive at Intuition Communication Ltd, blogged that in recent years, private hospitals had become more entrepreneurial in offering consultants and consultant groups financial incentives – but these would now certainly be on the way out.

He thought private hospitals would look again at how they ‘tie in’ consultants to their facilities.

But he wondered what would happen about other less obvious incentives consultants received for favouring a private hospital. For instance, the consultant who:

 receives free consulting rooms or secretarial support for private practice;

 receives funding from a private hospital for research or for attending a conference;

 r equests the purchase of an expensive piece of kit for his private practice. was this a financial incentive?

a dded Mr Pollard: ‘ a nd, of course, . . . who will monitor this kind of arrangement?’

He saw echoes of how the relationship between doctors and the pharmaceutical industry had changed. Drug reps were once given a budget and armed with giveaways to ‘encourage’ doctors to favour their company’s drugs. But those days were gone.

‘The Government forced the pharmaceutical industry to clean up its act. It looks like the private healthcare sector will suffer the same fate.

‘of course, this has direct financial implications for the private consultant. If the days of “free” consulting rooms and secretarial support are over, does this mean an increased financial burden for private consultants?

‘will private consultation and procedure fees increase and will some consultants opt out of private healthcare? The end result . . . higher prices and less choice for the patient?’

federation of independent practitioner organisations (fipo)

FIP o stated it backed measures that will prevent consultants’ incentives schemes and increase competition among them.

Deputy chairman Mr Chris Khoo

‘the cMa’s main allegation appears to be that hca is too successful, too efficient, too innovative. it wants to punish hca for that success

said: ‘we are entirely supportive of the authority’s desire to remedy adverse effects on competition.

‘In particular, we welcome the restriction on clinician incentive schemes that encourage patient referrals to particular facilities, and we agree with – and indeed have advocated for some time –the provision of fee estimates to patients and the availability of quality outcomes.’

He said FIPo was already working closely with the Private Healthcare Information Network (PHIN) to develop a website giving patients information to help them choose or find out more about an independent hospital. It would also provide more sophisticated clinical outcome data.

Mr Khoo added: ‘Having worked closely with the then Competition Commission on its study into the private healthcare market, we will now work with our member organisations to ensure these measures are implemented to the benefit of patients.’

Association of independent Healthcare organisations (AiHo)

Chief executive Fiona Booth said aIHo welcomed moves to guarantee objectivity and transparency that informed choice and quality for patients. It would now work with members to take the agenda forward.

Commenting on the CMa finding that a ‘lack of available information’ had resulted in patients being unable to make informed choices when selecting a provider, she said the trade association was backing the Private Healthcare Information Network (PHIN) as the best way to achieve data transparency and informed choices for patients.

‘as we detailed in a submission to the inquiry, PHIN publishes

data for the benefit of the patient and operates with the full support of aIHo members.’

private Healthcare information network (pHin)

Chief executive Matt James said the report set out a solid road map for improving information availability in private healthcare.

‘everybody in the sector wants to get on with it, and PHIN believes that this is already having a transformational effect.

‘Thinking back to the o FT’s round Table events in late 2011, it seems incredible to think that we now have support from across the industry for PHIN and the information agenda – endorsement from FIP o and the BM a , explicit commitment from Bupa, and continued involvement and support from the hospital operators that started it all.

‘we will soon have a standardised approach to coding, compatibility and direct comparability with NH s information, and a website for patients giving comprehensive quality and pricing information at hospital and consultant level.

‘ we will continue to work to build consensus and buy­in from all parties – for example, providing information for consultants before we consider producing any information about consultants. we aim to deliver meaningful information to patients while supporting the needs of every participant in private healthcare.’

Last month, PHIN held a workshop on P ro Ms that brought consultants, hospitals and insurers together in the first such genuinely collaborative exercise that anyone seemed to remember.

Mr James said this would be the first of many, setting a new tone for the industry. The preliminary outcome was hugely encouraging – clear support for jointly specifying an ambitious ProMs service that would be ‘a genuinely innovative differentiator for private healthcare for the next ten years’.

nuffield

Group chief executive David Mobbs claimed: ‘The reshaping of the London market will undoubtedly lead to reduced prices in central London, with the positive effects also felt by patients

‘the government forced the pharmaceutical industry to clean up its act. it looks like the private healthcare sector will suffer the same fate

throughout the rest of the country, who have for many years paid more than they should for private medical insurance to subsidise excessive London prices.

‘Improvements in access to clinical information relating both to hospitals and consultants, combined with increased transparency in fees means that consumers will at last be able to make informed decisions about which hospital and which consultant is best for them.

‘The removal of consultant incentives for referrals to individual hospitals means that patients will finally have real choice about treatment options, rather than it be dictated to them – this can only be positive for the consumer.’

private patients forum (ppf) The PPF majored on a re­iteration of complaints it has previously made critising the inquiry for ignoring the role of insurers. It believed if insurers had been included in the investigation, then problems that patients had highlighted to the forum would have been addressed.

But it did welcome greater transparency in incentive schemes, improved public availability of information on consultant fees and on consultants’ and private hospitals’ performance.

It said it would welcome lower private healthcare and private medical insurance (PMI) costs resulting from sales of HCa hospitals, but doubted this was likely.

Bmi

Following huge criticism and many words from BMI about previous plans to force it to sell off seven from possibly 12 of its hospitals, the group responded with a comparatively small statement. Chief executive stephen Collier

said it was ‘pleased’ the commission had been able to maintain its ‘open­minded approach’ throughout what had been a complex and wide­ranging inquiry into a sector still suffering from the effects of recession.

‘The commission has engaged openly with us and with our arguments and evidence to reach a sensible, measured and fair conclusion. I have no doubt that the remedies announced today will provide the whole sector with the impetus needed to open up to new ways of working in the continued best interests of patients.’

He said BMI had always supported measures to promote transparent, comparable quality and pricing information which patients, insurers and commissioners could use to help make informed choices.

added Mr Collier: ‘we therefore look forward to implementing these necessary remedies, which will lead to a step­change in the way private healthcare works and which will further enhance competition to the benefit of patients and purchasers of healthcare. we also welcome the new guidance on the relationship between hospitals and doctors.

‘after two years of uncertainty, we are now able to look forward in the knowledge that we can focus single ­ mindedly on what matters – providing our patients with the best possible care, based on the best available clinical and pricing information.’

private patient unit expert Philip Housden, of Housden Group, commented: ‘The head lines are being grabbed by the impact on HCa and non­impact on BMI hospitals. But this is too London and private hospital centric. In my view, the long opportunity for delivering increased competition in the sector lies with the continued renais sance of NH s private patient units (PPUs).

‘ will the remedies prove an irrelevance to PPUs? are they a threat or an opportunity for growth? restrictions on pre sent private operator incen tive schemes and future transparency on fees and performance can all be tools for PPUs to increase

awareness of the strengths of private care on an NH s campus to individual consultants, chambers and patients making a choice of where to be treated, based on quality and price.

‘In the long run, it could be the NHs that benefits most.’

Healthcode

The online solutions company said the report rightly addressed the need for meaningful quality and outcomes information and was pleased it has now established the criteria from which performance measures at hospital and consultant level will be determined.

Managing director Peter Connor said: ‘By stipulating the use of multiple coding classifications, the solution is perhaps more complex than it needs to be. However, Healthcode believes it is achievable and we have already developed the coding tools to help providers record the data they need for both billing and clinical purposes.’

ndependent doctors ederation (idf)

elcoming the report, the IDF said increased competition was generally healthy, but it was not able to judge if a divestiture of a major private hospital in London was likely to yield benefit.

But wellington and London Bridge had been flagship hospitals with an international reputation across the globe and had been developed to very high standards over the past decade. ‘ we would hope that any divestiture would not result in dilution of the quality of healthcare provided by these hospitals. we were intrigued that the proposed divestiture of hospitals outside London did not occur.’

We were intrigued that the proposed divestiture of hospitals outside London did not occur

It agreed with the CMa about consultant incentives and was ‘totally opposed to any incentive scheme that might influence clinical decision­making to the potential detriment of patient care. we do not tolerate any of our members behaving in this manner’.

The IDF was committed to working in partnership with PHIN and any other organisations to provide as much information on quality and outcomes to allow patients to make informed choices.

It also supported total transparency on the structures and services provided by consultants and private healthcare facilities.

‘ we strongly encourage our members to publish their fee structures in advance, particularly for self ­ pay patients and those patients whose private medical insurance is not adequate enough to cover the costs of services.’

Throughout this investigation, it had been surprised at the absence of any significant reference to the influence of insurers on the market. ‘PMIs are major stakeholders in the delivery of private healthcare often providing significant benefit and added value particularly to patients, but on occasions introducing restrictions on access of patients to private healthcare that may be potentially detrimental.

‘The CM a report seems to accept that it is normal for PMIs to direct the referral flow of patients to private healthcare facilities and to consultants. This “open referral” policy is contrary to the IDF view.’

‘ e qually, we were intrigued to note that the CMa did not consider that capping of fees by PMIs, particularly for newly appointed consultants, might be detrimental to the patient and to the private healthcare market in general.

‘Many of our members and indeed other consultant colleagues have expressed concern that the current capped rates of re­imbursement for new consultants are uneconomical, particularly for consultants who wish to provide a comprehensive initial assessment of patients.

‘we are concerned that this may reduce quality, innovation and indeed discourage young consultants from entering into private practice.’ 

under threat: the Wellington hospital, London

the Shard: London Bridge hospital’s expansion plans still going ahead

special report: the future of harley street

Breaking out of the enclave

Organisers of a summit set up to consider the future of Harley Street in a fast-changing world were swamped with 220 applications to attend after Independent Practitioner Today’s front page story in February. Robin stride reports on the outcome

C O n S ultant S and medical businesses within the Harley Street enclave have voted by a big majority to back a new initiative aimed at promoting the area and attracting more patients from abroad.

Seventy ­ one per cent of more than 200 interested parties at a special summit called to discuss the future of the brand in the face of increased competition overseas registered their support for some form of Harley Street ‘partnership’.

a nother 21% using an electronic voting system at the Royal Society of Medicine summit in london said they would back it if it was free.

But 8% chose to press the button for the third option and said they would not back it ‘at any price’.

the voting came at the end of a packed meeting featuring a parade of speakers – many drawing attention to massive medical marketing initiatives to attract overseas patients to other countries.

Keith Pollard, managing director of the meeting’s organisers Intuition Communication, told the summit there was a ‘medical tourism gold rush’ now going on in 32 countries while Harley Street was ‘sleeping’ and resting on its laurels. this was illustrated

Our February edition reported on the plans for the conference on the future of harley street

What the audience said What does the future of harley street look like to you?

Bright 12%, haven’t exploited its potential 75%, doing OK 4%, Past its sell-by date 9%

should we try to create a cluster?

Great idea 48%, Good idea 36%, undecided 9%, Poor idea 1%, Waste of time 6%

if there was a cluster, what would it focus on?

harley street 44%, London 49%, uK 7%

how important is the Middle east market to you today?

Very important 35%, important 43%, not important 13%, not important at all 9%

how good is harley street in meeting the needs of patients in the Middle east?

excellent 6%, Good 44%, Poor 30%, Very poor 4%, no idea 16%

at medical tourism conferences around the world, where he was often the only Brit present.

Mr Pollard said: ‘We are a phenomenal player in the medical tourism market, but the rest of the world doesn’t know.’

Giving consultants some practical advice, Mr Geoffrey Glazer, chairman of the Federation of Independent Practitioner Organisations (FIPO), warned them to avoid the danger of putting all their eggs ‘into one foreign basket’ as events in a particular country could suddenly prevent patients from continuing to travel.

He advised that Harley Street now had to face up to many chal­

Keith Pollard, head of intuition communications, the organisers ➱ p14

lenges. there would be increasing competition in london from nHS private patient units (PPus) and private hospitals too, such as the new KIMS development in Kent, due to open soon.

Medical tourism was happening worldwide and patients were increasingly more discerning and wanting to see outcome data.

Many in the audience were clearly surprised by slides Mr Glazer showed to demonstrate the sheer detail of information now being produced about consultants’ work by the Private Healthcare Information network (PHIn).

Interestingly, a narrow majority at the meeting would favour any ‘clinic cluster’ branding arising from the event to promote l ondon as the medical destination of choice (49%) rather than Harley Street (44%) itself.

Emerging competition to the uK includes South Korea, whose representative gave doctors and managers a flavour of the country’s strategy for international patients. Mr Phillip Kim said the number of overseas patients there had risen from 60,201 in 2009 to 159,464 in 2012 and the uS was now sending nearly as many patients there as China.

International healthcare consultant Elizabeth Boultbee gave a flavour of medical facility development in the Middle East –many of them vast. a healthcare city in d ubai now had 4,000 licensed professionals and there were many new hospitals being built in the area.

this raised the question of why should a consultant in the u K even bother to try and attract peo­

Mr Geoffrey Glazer, chairman of the Federation of independent Practitioner Organisations

did yOu KnOW?

 1,843 consultants have a practice address in the harley street area

 it is estimated 53,000 people came to the uK for medical treatment in 2013

 half the audience at the summit believed harley street was the place people went to for the best doctors

 the ‘cluster’ concept, featuring many medical facilities in one area as a brand, is generating business around the world. examples include Mexico, thailand and Florida

 dubai now has its own healthcare ‘city’, but of its outbound patients only 11% go to the uK while, 43% see German doctors ‘because they are doing a good job marketing themselves’

if you want to play in this market, there is an opportunity, but you can no longer sit in London and wait elizabeth Boultbee

 turkey is ‘pouring money’ into medical tourism, is building some massive developments and has a turkish healthcare travel council

 Malaysia healthcare travel council employs 42 staff and has five offices abroad

Source: Intuition

ple to travel to see them from these countries.

the answer was, she said, that patients were still travelling for treatment. In the u nited a rab Emirates, for instance, it was estimated that 30,000 residents a year were paying to see doctors abroad. london remained an attractive destination for Gulf nationals, but it was up to consultants and hospitals in the uK to be more transparent about prices.

Ms Boultbee said: ‘If you want to play in this market, there is an opportunity, but you have to have a strategy and a profile in the countries you are targeting. You can no longer sit in london and wait.’

a ccording to another speaker, there was also untapped potential

for private doctors in the u K to attract more Russians for treatment. But at the moment, warned consultant anaesthetist dr Sergei Vaganov: ‘ t he Russians don’t know you.’

He suggested better marketing and targeting of the u K ­ based Russian community would be a big help in breaking down current barriers.

dr Vaganov said difficulties in Russians getting a British visa was a big issue and other problems included the lack of Russianspeaking consultants and services in the u K, plus a lack of understanding of the British medical system. the uK was also relatively expensive compared to the rest of Europe.

But the typical Russian patient

was looking for the ‘best doctors’. they wanted people who would tell them what to do – not lay out the options – and give them a decent length of time in a consultation.

Fiona Booth, chief executive of the a ssociation of Independent Healthcare Organisations, said the industry clearly now needed to ‘shout more’ about its role and contribution.

Meanwhile, demand from doctors for medical premises in the Harley Street enclave is ‘extraordinary’, according to Howard dr Walden Estates property director Simon Baynham.

He said the property owners had a waiting list of doctors who wanted to come into the area and be tenants. 

international healthcare consultant elizabeth Boultbee

Make sure nobody is left behind

Help prevent shingles disrupting your patients’ lives. There is a 1 in 4 chance of people developing shingles during their lifetime.1 You can help protect eligible patients who were aged 70 and 79 on the 1st September 2013 by vaccinating them under the national shingles immunisation programme.2

ABRIDGED PRESCRIBING INFORMATION

ZOSTAVAX® powder and solvent for suspension for injection in a pre-filled syringe [shingles (herpes zoster) vaccine (live)] Refer to Summary of Product Characteristics for full product information. Presentation: Vial containing a lyophilised preparation of live attenuated varicella-zoster virus (Oka/Merck strain) and a prefilled syringe containing water for injections. After reconstitution, one dose contains no less than 19400 PFU (Plaque-forming units) varicella-zoster virus (Oka/Merck strain). Indications: Active immunisation for the prevention of herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in individuals 50 years of age or older. Dosage and administration: Individuals should receive a single dose (0.65 ml) administered subcutaneously, preferably in the deltoid region. Do not inject intravascularly. It is recommended that the vaccine be administered immediately after reconstitution, to minimize loss of potency. Discard reconstituted vaccine if it is not used within 30 minutes. Contraindications: Hypersensitivity to the vaccine or any of its components (including neomycin). Individuals receiving

immunosuppressive therapy (including high-dose corticosteroids) or who have a primary or acquired immunodeficiency. Individuals with active untreated tuberculosis. Pregnancy. Warnings and precautions: Appropriate facilities and medication should be available in the rare event of anaphylaxis. Zostavax is not indicated for the treatment of Zoster or PHN. Deferral of vaccination should be considered in the presence of fever. In clinical trials with Zostavax, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggest that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts (for example, VZV-susceptible infant grandchildren). Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported. This is a theoretical risk for vaccination with Zostavax. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact. As with any vaccine, vaccination with Zostavax may

not result in protection in all vaccine recipients. Zostavax and 23-valent pneumococcal polysaccharide vaccine should not be given concomitantly because concomitant use in a clinical trial resulted in reduced immunogenicity of Zostavax. Pregnancy and lactation: Zostavax is not intended to be administered to pregnant women. Pregnancy should be avoided for one month following vaccination. Caution should be exercised if Zostavax is administered to a breast-feeding woman. Undesirable effects: Very common side effects: Pain/tenderness, erythema, swelling and pruritus at the injection site. Common side effects: Warmth, haematoma and induration at the injection site, pain in extremity, and headache. Other reported side effects that may potentially be serious include hypersensitivity reactions including anaphylactic reactions, arthralgia, myalgia, lymphadenopathy, rash and at the injection site, urticaria, pyrexia and rash. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic cost: Vial and pre-filled syringe with two separate needles. The cost of this vaccine is £109.20. Marketing authorisation holder:

Sanofi Pasteur MSD SNC, 8 Rue Jonas Salk, F-69007 Lyon, France Marketing authorisation number: EU/1/06/341/011

Legal category: POM ® Registered trademark Date of last review: October 2013

References 1. Miller E, Marshall R, Vudien J. Epidemiology, outcome and control of varicella-zoster infection. Rev Med Microbiol. 1993; 4: 222-230. 2. Tripartite letter (Department of Health, Public Health England, NHS England. Gateway Reference Number:00254) “Introduction of shingles vaccine for people aged 70” 12th July 2013.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291.

Let’s not be too fast to polish off the NHS

GP and author Dr Benjamin Daniels philosophises on why the private sector isn’t the answer to the problems of the NHS

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Much as I love the principles of the Nhs, I don’t live in a bubble and I would be the first to admit that it can be a bit rubbish sometimes, as can some of the people who work within it. We need to constantly root out our failings and strive to improve it from within.

s ometimes this feels like an impossible task and when the Nhs is on the receiving end of a constant barrage of abuse from the media, it can be tempting to look to the private sector as a way out.

a private health clinic recently asked me if I’d consider leaving the Nhs to become a private GP. I said no, and for two reasons.

The first was that if patients are really sick, there is nothing better than our local N hs services. s econdly, I became a doctor to provide sick people with what they need, rather than offer well people what they want.

envy of the world?

The Nhs is the envy of the world … although apparently it’s not the envy of many Polish people living in the uK.

such is their dissatisfaction with our healthcare system, many of my Polish patients go home to seek medical care and two Polish doctors have set up their own private clinic in London, which is apparently thriving.

I could quote data showing how good our health care outcomes are in comparison to other nations, but for most people, personal experiences of care outweigh any

statistical evidence that I can offer. One of my young Polish patients asked me why doctors in the Nhs only prescribe paracetamol. The answer is, of course, that we don’t. I prescribed him paracetamol for his slightly sore knee and explained that it would get better on its own.

h e told me that in Poland he would have got an X-ray and seen an orthopaedic surgeon. I also prescribed him paracetamol for his viral sore throat.

In Poland, his doctor would have apparently performed a chest X-ray and given antibiotics. I have prescribed him only simple painkillers for his ailments because they are benign and, due to the amazing self-healing power of the human body, they will get better all on their own.

expensive investigations

he is a fit 28-year-old who doesn’t need extensive medical investigations for his minor health complaints, but were a privately-run health clinic to be set up in our local town, I suspect he would happily part with £70 to see a non-Nhs GP. I’ve not seen many private doctors prescribe a cheap drug like paracetamol when they can prescribe numerous more expensive ones.

It would also be lucrative for a private practitioner to order as many expensive investigations as possible. These should be done quickly, as once the patient gets better, he may not be quite so willing to part with his credit card details.

Going against the grain, I do have one Polish patient who isn’t quite so critical of the Nhs she is only 23 years old and has been working here as a waitress. s he came to see me one afternoon with a lump on her arm.

It was hard and craggy and felt like it was attached to the bone. I placed her urgently on the cancer referral pathway and within ten days she had seen a specialist, who unfortunately agreed with my diagnosis.

top-notch treatment

she had an osteosarcoma and it needed urgent treatment. she was sent to the Royal National Orthopaedic hospital in London where she received top-notch cancer treatment and the sort of specialist surgery that only a few places in the world can offer.

Now she is back at work with only a small scar on her forearm to remind her of her recent brush with death. she went back home to Warsaw last month to take her notes and scans to a Polish doctor for his opinion. he told her that the management for her condition in Poland would have been to amputate her arm above the elbow.

Those most ill tend not to be the ones who complain loudly

The private clinics steer well clear of those who are seriously unwell, as there is no money to be made from them

about the Nhs a person who has been hit by a bus or is being treated for cancer tends to sing praises for the treatment they receive.

The private clinics steer well clear of those who are seriously unwell, as there is no money to be made from them. I can’t imagine a team of private doctors offering to set up an independent a &E department.

cherry-picking

The private sector prefers to cherry-pick the fortunate majority, who are basically fairly well but are often disgruntled with the Nhs. The private healthcare system in the usa is extremely lucrative for the same reason. They also make their huge profits by targeting their services to well people.

For example, they have scared the population into believing that they all need yearly colonoscopies

to screen for bowel cancer. Each colonoscopy test costs on average $1,185, while here in the uK we test poo for signs of bowel cancer instead, which costs around £10. studies suggest that both techniques have similar levels of effectiveness as a screening tool, but the american insurance companies can’t make any money out of a £10 poo test.

Of course, the real crime in the usa is that people with bowel cancer but no health insurance die, unable to afford a colonoscopy or the potentially life-saving treatment they need. Thank goodness for the Nhs 

Adapted from Further Confessions of a GP , by Dr Benjamin Daniels, published by The Friday Project, £7.99. This is a follow-up to Dr Daniels’s bestselling (400,000+) Confessions of a GP. It is available for purchase now on Amazon and at all good book retailers

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TAx AllowAnCES

Don’t wait until the rush is on at the end of this new 2014-15 tax year. Make plans now to fully utilise allowances and exemptions throughout the months ahead. Mike Willoughby recommends some key areas to look at

Look ahead to

Capital gains allowance

The annual exemption from capital gains tax (CGT) is £11,000 per individual for the 2014-15 tax year.

For those above the basic rate limit, paying tax at 28%, this exemption is worth £3,080 (£6,160 per couple). You should consider crystallising gains up to this limit.

Start a Junior ISA or pension for your kids or grandkids

Junior ISAs provide a very taxefficient savings vehicle for parents, family members and friends to invest up to £3,840 in this tax year on behalf of a child.

Sim ilarly, you could consider setting up a pension plan for a child or grandchild and making a net payment of £2,880 (£3,600 after basic-rate income tax relief).

Annual inheritance tax gifting exemption

You can give away up to £3,000 a year and you can also carry over unused allowance from the preceding year. These gifts will be

You can give away up to £3,000 a year and you can also carry over unused allowance from the preceding year. These gifts will be exempt from inheritance tax when you die

exempt from inheritance tax when you die.

Small gift exemption

You can also make small gifts of up to £250 every year to as many people as you like – but you cannot use this exemption with the £3,000 annual exemption for the same person.

Or you could instigate regular gifts from income to reduce your inheritance tax liability.

Firm pension contributions

If you operate your private practice through a limited company and employ your spouse or partner, there are some excellent opportunities to reduce the liability to corporation tax by making a significant pension contribution to them as an employee.

Unlike personal contributions, contributions made by employers are not limited to 100% of relevant UK earnings. In addition, a ‘carry forward’ of unused allowance can be applied for employer contributions as well as personal contributions.

Not only can a well-drafted will mitigate inheritance tax, it is also crucial for anyone wanting to protect their family from a huge headache after they die

Venture Capital Trusts (VCT)

These schemes are designed to assist small unquoted, trading companies to raise capital by offering tax incentives to investors. VCT investments provide income tax relief of 30%, subject to an maximum of £60,000 (£200,000 @ 30%), provided the investment is held for five years.

Gains are free from CGT, and dividends are paid tax-free, although the 10% tax credit is not reclaimable.

Enterprise Investment Schemes (EIS)

These schemes invest in a very similar way to VCTs, but provide greater tax incentives to investors. These include income tax relief of 30% up to a maximum of £300,000 reclaimed tax in any year and there is a carry-back facility to obtain tax relief for the previous tax year.

Gains on realisation are free from CGT, there is unlimited CGT deferral for gains made up to three years ago, and the full value

is free from inheritance tax after two years.

All VCTs and EISs must invest in unquoted UK smaller companies and such companies, by their nature, involve a higher degree of risk than some investment in larger companies.

As such, there is a risk that any of the investments may not perform as hoped and, in some circumstances, fail completely.

Also, due to the nature of underlying assets, VCTs and EISs are fairly illiquid and investors must be aware that they may have difficulty or be unable to realise their

to use tax breaks Expert

shares at levels close to that which reflect the value of the underlying assets.

So this type of investment should not be considered unless you are willing to accept a higher level of risk.

Reduce inheritance tax –

Make a will

One of the simplest inheritance tax mitigation tools is a will. Not only can a well-drafted will mitigate IHT, it is also crucial for anyone wanting to protect their family from a huge headache after they die.

Only with an appropriately drafted will can you be certain that your estate will go to the right people.

If you do not have a valid will, you risk depriving your family of their home, increasing the inheritance tax burden and leaving parts of your estate in the wrong hands.

Individual Saving Accounts

The ISA allowance rose to £11,880 this month and from 1 July ISAs will be simplified with the creation of the ‘New ISA’ (NISA).

From then the limit will go up to £15,000. This really is a most

valuable opportunity for doctors and their spouses to provide income or build capital for the future.

All of the new limit may be invested in cash deposits, rather than the current 50%.

NISA investors will be able to transfer their investment from a Stocks and Shares ISA to a Cash ISA.

Currently, transfers are only poss ible to Stocks and Shares ISAs.

Mike Willoughby is a partner at St James’s Place Wealth Management

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AccoUnTAnT’s clinic

Jobs for new tax year

The beginning of a new tax year always provides new opportunities and some new issues. Susan Hutter looks at what you should be considering for you and your practice

PEnsions

Successive governments have been threatening to simplify the pension system in the UK for as long as most of us can remember. That does not appear to have happened yet – in fact, it has become even more complicated.

There are two main issues facing you and your practice:

1. The nHs Pension scheme and private pensions

Most Independent Practitioner

Today readers will have been at some point involved in the NHS Pension Scheme even if they may have opted out recently or retired from the NHS while retaining a private practice.

Many will also have a personal pension scheme under which they have been offsetting the premiums against their private practice income in order to obtain the tax break.

On 6 April 2014, the lifetime allowance decreased to £1.25m and the annual allowance to £40,000. Doctors would have had to notify HM Revenue and Customs by 5 April 2014 if they wanted to rely on ‘fixed protection’ as far as the lifetime allowance is concerned, but hopefully those on the borderline have taken advice by now.

Looking ahead, everyone needs to bear in mind whether or not they are likely to breach the lifetime allowance in the near future and also whether the annual allowance is going to be breached on a year by year basis.

If the annual allowance is breached – i.e. the doctor pays or accrues benefits of more than £40,000 in their pension scheme – there will be a tax charge at their marginal rate of tax on the excess.

So there is a need to plan ahead and it is important to take advice from a financial adviser who specialises in medical pensions.

2. Auto-enrolment

Doctor employers may have heard about auto­enrolment. The scheme was introduced in 201213 for larger employers and will affect all current employers by April 2017.

Under auto­enrolment, all your staff will automatically be enrolled into a compliant pension scheme and you will need to make pension payments on their behalf unless they opt out.

The staging date for entry depends on the size of the practice. In order to find out when auto ­ enrolment affects you, log into the Government website www.thepensionsregulator.gov.uk/ employers/tools/staging­date.aspx where you will guided through a few simple steps to work out when your enrolment date is. You will need your PAYE reference to hand.

It will be a minimum employer contribution and, once again, the above website will show you how to calculate this. It is not particularly expensive; the expense

comes with the cost of the set­up and running the scheme in future.

Under current legislation, to comply with auto­enrolment, you have to go through a number of hoops and you will probably need to take advice from an independent financial adviser.

It is a fairly complex procedure and you should consider taking advice at least six months before your enrolment date.

Do find out your enrolment date sooner rather than later so that you can make sure you are prepared.

sAlARY lEVEls

Many consultants or private GPs may employ non­taxed or lowerrate tax ­ earning spouses in the practice and pay them up to a maximum so that no tax or National Insurance is payable.

If you do this, then you may wish to review the salary levels, as the lower earnings threshold went up to £10,000 on 6 April.

One word of warning – HMRC is keen that you can justify the salary levels paid to spouses and other family members and therefore you must be able to do this.

REsEARcH AnD DEVEloPMEnT (R&D)

There are extra tax incentives for those doctors who invest in R&D within their practices. This only applies for those who are incorporated and so trade as a limited company.

If you do have qualifying R&D expenditure, you will be entitled to extra corporation tax relief equivalent to the amount of the qualifying expenditure.

For example, if you spend

£25,000 on qualifying R&D, without an R&D claim, you will get tax relief on the £25,000, but with a successful R&D claim, you actually get tax relief on £50,000. You will need to take expert advice about what qualifies and what does not qualify, but it is certainly worth looking into.

BAnK RATE

There has been a lot of press speculation about the future of the bank rate and whether or not the recent low levels can be maintained. The Governor of the Bank of England has said they will be for the next few years at least, but other economic commentators seem to disagree. If you have large loans for your practice, or indeed for personal property, it is worthwhile looking into the fixed ­ rate options – so you know where you stand over, say, the next three years.

isAs

The beginning of the tax year is a good time to review your Individual Savings Accounts (ISAs) investments. The maximum investment in 2014 ­ 15 is £11,880, of which £5,940 can be in a Cash ISA. From 1 July, the allowance will rise to £15,000 and, for the first time, all of it can be put in a cash New ISA (NISA). It is sensible to start planning early in the tax year as opposed to the end of the tax year, as one can drip­feed into a Stocks and Shares ISA, which spreads the risk as opposed to putting in one large lump sum. n

Susan Hutter is a partner with Shelley Stock Hutter LLP. She provides specialist accounting, taxation and business advice to the medical and healthcare industry

Working with a

The relationship between a consultant and their personal assistant is crucial if they want to deliver effective medical care. Ideally, the strength of this union is formed out of mutual respect at the onset – but what if this is not the case? Michael Bolt shows how to get the best out of the relationship

Spotting dySfunctional relationships is not hard. typically, consultants complain of not being supported well enough and pas conversely say their consultants do not value their role.

in reality, to have a truly effective working relationship, a number of guidelines need to be adopted.

and although it is true that a pa will never be able to provide medical care, equally, though, a consultant will not be able to function at the highest level without administrative support.

Here are some tips to help this relationship be successful. adhere to them fully and it will flourish.

Working with your PA

1

Upright Positional MRI

A new concept providing real benefits to patients

• Weight-bearing scans and variable patient positioning enables a more precise diagnosis

• Truly open system is a solution for claustrophobic patients without compromise in image quality

Future planning

in many cases, relationship problems start during the recruitment phase because the usual job spec has been trotted out without a great deal of forethought.

Essentially, the candidate is doomed to failure. take time to consider what their role will involve. Why did the last person leave? What was wrong? find it, fix it and write the right job spec.

2 Aligning skill sets

Would you know if your pa speaks french? or has an accounting qualification?

More often than not, you will find your employee wants to do more than you originally expected, but if you don’t ask or they don’t tell, you may be missing out. poor staff performance is often due to their feeling a lack of appreciation.

Don’t wait until the chips are down to make sure your PA knows what you need

Although it is true that a PA will never be able to provide medical care, equally, though, a consultant will not be able to function at the highest level without administrative support

3

Managing downtime

Sick days cost business billions every year. not because people are sick, but because there’s no effective plan in place to manage it.

p eople get sick; you won’t change this. But what you can change is your ability to not let it affect your business. if you have prepared with a clear set of expectations on what your pa should do in case of illness, then downtime can be managed effectively.

4

Right tools for the job

Having the right tool for the job is as right for the medical professional as it is for their pa

d on’t ignore a pa’s ability to communicate exactly what is needed in this area.

But, even better, find the best solutions using their wealth of experience.

t hen ensure everyone is well trained – it will pay enormous dividends.

5

Effective communication

Every team member needs to understand the goals ahead to achieve success.

d on’t wait until the chips are down to make sure your pa knows what you need.

Make it the first thing, every single day.

let them know how you think: it will only serve to benefit your working relationship, yourself and your practice.

Working with a consultant

iM proving t HE relationship with your boss is always going to be a challenge.

they are busy providing clinical care; you are balancing their needs and the needs of the practice, which often means the opportunities to communicate are missed.

t hese points will help you achieve a better balance.

1 set your objectives

Knowing what your consultant is trying to achieve for themselves and their practice and where their priorities lie is paramount to a seamless relationship with them.

if you do not know this, make sure you find out. this will help you, in turn, prioritise and gain the information you need to succeed personally.

2 Don’t plan to fail think ahead. planning to fail will leave you fire­fighting on a daily basis. you need to be prepared for changes before they arise. Have processes in place so any last ­ minute adjustments can be tackled with efficiency, causing as little disruption to your day as possible.

3

Allow for bad habits

this will ensure that you are one step ahead and can be prepared to work with them or

Don’t overload your consultant with irrelevant or unnecessary information

correct them as they arise. Eliminating potential issues before they happen will make your job easier.

4 Filter information

don’t overload your consultant with irrelevant or unnecessary information. Knowing what you should and shouldn’t share often comes with time, but also applying common sense is required. this will also ensure the points and subjects you raise and note are absorbed and retained. More importantly from your perspective, anything you do raise is likely to be responded to more swiftly.

5 stand your ground

i f you have planned, prepared, considered and noted all that you have worked on, be confident in your communication and work. your confidence will be noted and relied upon.

a s with any business, all elements of the team have to work together to achieve its goals. Medical care is no different in that regard, although the nature of the business will apply acute pressure if cracks start to appear.

i f that occurs, consider new solutions to the standard route of employment, as they may allow for greater flexibility and, ultimately, lead to improved levels of service in your administrative team. 

Michael Bolt (above) is managing dir ector with Need More Time Ltd, providers of virtual assistant services for medical consultants and private practices

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The smoke and mirrors of SEO

For independent practitioners trying to get noticed, it is not their search engine ranking that matters, nor the amount of traffic going to their website, claims surgeon Dev Lall. What really matters, he argues here, are the numbers of visitors to your site who are converting to paying patients

If there is one question I’m guaranteed to get asked about by any consultant with a website, it is to do with search engine optimisation or SeO.

Why? Because SeO is often promoted by web designers as a way to get more traffic to the doctor’s new website and so more patients.

What exactly is SEo and why the interest in it?

Before we can answer that, we need to back-track and look at what happens when we search on the internet.

Google is the most popular search engine in the world and its stated aim is to provide people using it to search the internet with the best possible results. In other words, results most relevant to the search they are performing.

So although Google is a multibillion dollar corporation off the back of selling advertising, its primary and explicitly stated interest is in providing the best possible search results it can.

And this is entirely believable, because if you put in the search term ‘hernia surgeon London’ and you got a list of websites about tropical fish, you would

very rapidly stop using Google and move to Yahoo, Bing or one of the other search engines. And if their user base disappears, so will the advertisers.

Now, although millions upon millions of people are searching using Google and the other search engines every minute of every day, the pages they visit tend to be those on the first page of the search results, occasionally extending onto the second page.

We all do this and, furthermore, the pages most visited are those that appear highest on page one of the results.

the higher up the results page, the more visitors (‘traffic’) to your website, and because a proportion of those visitors will buy your product or service, the more income for your business.

So SeO comprises the strategies people employ to get their websites as high as possible in the natural search results, ideally in the number one position on page one of Google.

The conflict

But, in my view, there’s a problem. the ways by which Google and the other search engines decide how to rank pages of websites in terms of relevance to whatever search term you put in is a very closely guarded secret.

No one outside Google knows the algorithm. But we do know some of the elements Google considers to be important. Aspects such as social signals, number and quality of backlinks to the page, and keyword density.

So there’s an arms race. Google is trying to serve up the best and most relevant search results it can, while businesses are doing their damndest to find ways to beat the system to come up top of page one of search results for particular search terms.

SeO experts are constantly trying to find and exploit loopholes in the algorithm – as happened in the Penguin 2.0 update.

And as soon as Google cottons onto each new strategy, it patches the holes – as in the Penguin 2.1 update.

how is SEo done?

What it boils down to is deciding what keywords you want to come high up in the search results and

then implementing strategies to achieve this.

A general surgeon in London therefore might want to come up number one on page one of the search results if anyone searches for ‘best hernia surgeon in London’, because that would likely mean more private patients for him.

White hat SEo

‘White hat’ S e O is S e O that Google approves of. this means your site has good relevant content, which is the most important factor by far.

It also means structuring your site and labelling the content with tags so as to make it easily found and indexed by the Google software robots. It also involves sharing your content with social media platforms to encourage backlinks (‘off-page SeO’)

It is a good idea to have basic, ‘white hat SeO’ done, as your site is built (‘on-page S e O’). t his is very simple and straightforward to do.

Unfortunately, very few web designers know how to do it properly. too many web designers only know how to make your site look pretty, not to make it functional. Unfortunately, it takes a huge amount of time and effort to come up high in the search rankings with ‘white hat’ SeO. this is because to do so relies upon excellent content being organically syndicated around the internet

Very few web designers know how to do seo properly. Too many web designers only know how to make your site look pretty, not to make it functional

and commented upon favourably on the social media platforms, which is highly unpredictable and takes time.

And don’t forget the competition. t he screenshot on the left shows what you get if you search for the term ‘best hernia surgeon London’ into Google: there are 416, 000 pages which fit the term. Nearly half a million pages. And you want to come up NUMBer ONe of those 416, 000 search results?

Good luck with that.

black hat SEo

this is why SeO experts go down the ‘Black hat’ route to try and artificially game the system. they try strategies such as:

☞ Buying backlinks.

☞ Introducing excessive keyword density in your content.

☞ Buying social signals such as t weets, social media ‘likes’, Youtube video views and so on.

☞ Using software to do the above. t here is freely available software that can create thousands of fake social media signals, tweets, likes and backlinks in no time.

☞ Outsourcing to workers in the third World who are paid to visit your website, leave positive social media signals and comments.

☞ t ailoring your content according to the search terms people are already using to find your web pages (more on this shortly).

The myth of the free lunch

Yet there is no such thing as a free lunch – or traffic in this case.

A new tactic in SeO might work for a few months, then the loophole gets closed and your page ranking will fall again.

And if Google thinks you are gaming the system, it will ‘sandbox’ your website – in other words, it serves up your site on page 200 for 90 days so you never get found unless someone types in the exact domain name.

If you consistently breach its terms and conditions of use, Google many even de-index your website – so it won’t serve your website up in the search results at all. t his is the worst possible thing that can happen and will mean deleting the entire website and domain and starting from scratch.

even if you succeed in getting on page one in the search results, it could all disappear literally overnight when – not if – Google changes its algorithm, which it does every few months. You could literally go from page 1 to page 100 with no come-back whatsoever on Google.

SeO takes time to yield results. And the more competitive the keyword, the longer it takes to see an improvement in your ranking, taking a minimum of 2-3 months to see any improvement at all.

f inally – and this is a biggie –one of the central planks of SeO is that you find out what searches people are doing and what keywords people are using to find your website, then you optimise your content accordingly.

Until recently, that was not a problem, as Google was using the http: protocol for searching. Unfortunately, by default, Google is now using the https: protocol.

In other words, not only is it using a ‘secure’ method of communication but it is also stripping out the keyword and other information you need to know to intelligently inform an SeO campaign.

And this, in turn, means all your SeO efforts are being done in the dark, completely blind. Not a strategy for success.

I wonder who has the time and knowledge in private practice to police the SeO work? It seems to me that the only sure way to measure the success or otherwise of an SeO campaign is to look to see if your page ranking is slowly improving.

Yet not only do you need to allow a minimum of two to three months for this to happen – especially for the more competitive keywords – but if you are not high up in the rankings, it is of no benefit to you.

If you are not in the first three or four results on page one of Google – say, you are on page three – well, you might as well be on page 503, because appreciable numbers of people still won’t visit your website.

Yet consider this: in the end, it is not your ranking that matters, nor is it the amount of traffic to your website: it’s the numbers of visitors to your site that are ‘converting’ to paying patients – that is the only metric that matters.

To recap

 SeO does not equate to free visitors to your website, however you go about it. It takes time and money to manage.

 traffic though SeO is not under your control: Your page ranking –and thus visitor numbers –can evaporate overnight when, not if, Google updates its algorithm.

I personally know of companies who used to be earning hundreds of thousands of pounds a month through customers driven to their sites by SeO who found that, with a Google update, all their traffic disappeared literally overnight. revenue too dropped overnight to virtually zero and the companies concerned sunk.

 S e O traffic is not necessarily profitable. the quality of SeO traffic is falling rapidly, for reasons that are not clear. In other words, visitors to your website through the efforts of SeO are not as likely to become paying private patients as traffic through other means.

 SeO traffic is volatile.

In my opinion, it would be unwise to rely upon the by-product of a free service offered by a vast corporation with very different business goals and priorities to yours, whom you have absolutely no comeback against.

the good news is that there are very many more predictable, controllable and scalable means of increasing visitor numbers to your website and so growing your private practice. I wholeheartedly recommend using them instead. 

Dev Lall is an upper -GI surgeon and runs a specialist private practice consultancy. He is the owner and director of www.PrivatePracticeExpert.co.uk

Ensuring success of your group practice

Following Maitland Cook’s article last month about sure-fire ways to ensure your partnership is a failure, he now sets out basic guidelines to help you make it successful

MY FInAL sentence in my article last month included ‘with some simple guidelines and attention to detail, the position of probable failure can be reversed’.

So if you are currently in a partnership without clear guidelines or divisions of responsibility or an ongoing financial reporting system, then … it is not too late.

Change, start again, agree with your partners that things can be made better.

But if you are creating or joining a new partnership – of any size, shape, specialty or otherwise – start from scratch utilising the guidelines that minimise the

chances of failure and maximise the possibility, even probability, of ensuring success.

Personal ownership and responsibility

The most basic quality that can be brought to any business venture – and never forget that the practice partnership is a business venture – is personal ownership and responsibility.

Over the years, time and time again this personal ownership has proven the difference between a real success and average performance.

How many times do you notice

the difference between an owneroccupied and a managed pub or restaurant?

The personal attention of the owner is usually the difference and the reason one goes back again and again. It is the same in all service industry outlets.

Without any doubt, the medical profession in all its forms is a service industry. In aiming for success, the basic ethos of that industry must be adhered to at all times.

Treat your practice business like your own home; keep it personal, ensure the attention you give to your own home is mirrored in your practice and partnership.

Attention to detail

Many years ago, and through a period of over 20 years, the chief executive of a large group of surgical clinics in the UK would carry out a quarterly inspection of each of his units, always accompanied personally by the clinic manager.

The inspection involved visiting every room in each establishment and talking, albeit briefly, to every member of the team, whatever their position on duty that day.

One thing he always did was inspect the ladies’ lavatory ... including the underside of the lavatory seat. He firmly believed that if it was clean, the manager was on top of the job. Invariably, he was right.

This attention to detail and personal ownership are the two most basic qualities that may ensure success.

A legal agreement

From this philosophy – and it is neither complicated nor sophisticated – all else flows. The practice set-up will be clear and backed up with a legal contract and agreement.

Either a limited liability partnership (LLP) or a limited company (Ltd) will cover all the possibilities and requirements of the partners.

Premises security

The premises from which the practice operates will be secured on a freehold or leasehold agreement so that security of tenure is guaranteed on which the business can be built.

Defined responsibilities

Every practice should have an organisation structure illustrated by an organisation chart. This will show the responsibilities of all the team, be they partners or employees, clearly defined, with a backup document for each individual detailing the exact nature of their role and their reporting trail.

Reporting system

To ensure the partnership gets value from this structure, a simple system of reporting needs to be planned and implemented. Daily, weekly, monthly, quarterly and annual reporting to cover all aspects of the administration and to include every area of operation is essential.

Weekly meetings

Even more essential is that the partners create time to have a weekly meeting to consider the information supplied. This meeting need not be more than two hours in duration or, if more convenient, it can be two meetings a week of only one hour.

Key performance indicators

The key performance indicators (KPIs) are the bedrock on which measurement and analysis takes place.

☞ Daily information should include number of patients seen/ treated, income earned, clinical incidents.

☞ Weekly should be the summary of the daily information to create the week’s performance. In addition, it should include the debt position, bank liquidity, authorisation of purchase orders, review of staff costs for previous week, particularly agency and bank staff costs.

☞ Monthly management accounts should be produced by the second or third week of the following calendar month.

Performance comparisons

It is always helpful to compare monthly performance to the previous year and also to any business plan that may have been produced. A year-to-date (YTD) comparison is also always useful.

The quarterly and annual meetings follow on to analyse overall performance and set the strategy and tactics for the next quarter

Your partnership is your practice, your livelihood, your future, your pension and possibly your legacy. Taking it as an equal priority to your clinical work can be just as rewarding and will ensure that, when you are doing your clinical work, you are also completely focused to the benefit of your patient

and forthcoming year. At year end, a review of the success and failure should ensure the correct aims and targets are set for the future.

In analysing all this data, the partners can use the information to keep tabs on the business success or otherwise and also monitor the trends the business is showing.

Business plans

In the paragraphs above, there is reference to business plans and YTD comparisons – obviously these figures are not available in a start-up situation.

However, if the business/partnership starts this analysis and

reporting system from the first day of trading, the figures will be available forthwith as the partnership moves forward.

Creating a business plan from the beginning is beneficial in so far as its creation makes the partners consider their expectations from the business in the current year and the future. It also ensures all keep their ‘feet on the ground’.

Intelligent use of all this weekly through annual information ensures the business is and remains focused on its strengths and weaknesses at all times. Trends will become clear and difficulties or underperforming services and personnel will manifest themselves.

By doing all the above, the direct business activity will be both clear and under control from the top.

Management

Then there are the indirect aspects of the business activity to be managed. These include:

 The property;

 The specialist equipment;

 The general equipment;

 The IT services;

 The HR activity;

 The development plan;

 The bank;

 Any capital financial matters.

On the clinical side, there are all aspects of clinical governance including registration and compliance, including health and safety, infection control and private medical insurance agreements.

If the organisation chart and back-up has been properly considered and structured, all the above will have been included and the management of these essential activities allocated to an individual including, but not necessarily, the partners themselves.

In the regular meeting schedule, these matters should all be included on the agenda and written up in the minutes so they are followed through in a timely fashion.

The principle of the weekly meeting is to ensure small amounts of information are digested and recorded so that no single task becomes too much for one person, nor ever becomes too big to bring and keep under control.

Medical advisory committee

All clinic operations must have a medical advisory committee (MAC) to consider all aspects of clinical performance, including the granting of practising privileges.

However, the principle of the smallest partnership having a quarterly meeting of a MAC to consider all clinical aspects of the partnership performance is to be encouraged.

Analysing ‘black and white’ statistics very often brings home clearly potential or actual problems. Infection control and clinical incidents are both extremely important aspects of this reporting process.

Each partner should be given overall responsibility for different

aspects of the partnership performance and the reporting and monitoring as outlined above. The partners are the equivalent of the directors of a limited company and they must take their responsibilities accordingly.

In principle, it is always much less stressful to work in a properly run business than to work in chaos. Directors of efficiently run companies sleep much better than those who get by on instinct. Even when times are hard – in fact, particularly when times are hard – the efficient, focused, managed organisation will almost always succeed over the less efficient one.

Your partnership is your practice, your livelihood, your future, your pension and possibly your legacy. Taking it as an equal priority to your clinical work can be just as rewarding and will ensure that when you are doing your clinical work, you are also completely focused to the benefit of your patient.

Your patient is your priority at all times. To give them the best, ensure you are giving your partnership and yourself the best possible opportunity of both succeeding.

Business administration is by no means rocket science. It is the personal attention to detail and ownership of both that will give you, your partners and your partnership the best opportunity of success.

Once you have done this, you can concentrate on your trained vocation: to look after your patient.

In conclusion, it has to be accepted that the marriage of individual medical services to the commercial world will always remain a complex balance.

But if the participants in any group or practice partnership set up their venture to continue to honour the basic ethos as set out in this article, all the difficulties can be overcome to the great benefit of the partnership clients, the patients and also to the personal and financial satisfaction of the partners. 

Maitland Cook (left) is director of The Cadogan Clinic and also founder/director of Maitland Cook Medical Management Services Ltd

coMPETiTion FURoRE

HCA vows to battle on

HCA is coming out fighting over the competition body’s plans to force it to sell off prestigious hospitals. But meanwhile, as commercial director Keith Biddlestone tells Robin Stride, it is ‘business as usual’. So it’s putting another £120m into its facilities over the next two years…

WHEn nEWS of the possible forced sell-off of the UK’s largest acute private hospital, The Wellington, filtered through to the 1,000 people working there on 2 April, it sounded like All Fool’s Day had been granted a 24-hour extension.

Shock and bewilderment soon set in as reality banged home.

Yes, there could be a reprieve for the threatened HCA’s London Bridge Hospital and its Princess Grace Hospital. But The Wellington would have to get the boot instead. Oh, and also its £33m Platinum Medical Centre, billed by Independent Practitioner Today at its opening only three years ago as a ‘turning point for private medicine’.

And how many would BMI have to sell? Err, none. The plan was to divest seven, but two of the competition body’s five strong group – its chairman Roger Witcomb and Jayne Almond – swayed the vote in BMI’s favour.

Unlike many older healthcare facilities, the Platinum was designed specifically around the needs of its doctors – who helped shape it – and the 70,000 outpatients expected to attend every year.

257 consultants took the trouble to write to the Competition Commission to tell them it had got things wrong. now, responding under its new name adopted on 1 April, it laid down a Sophie’s Choice-style ultimatum.

Some of those consultants reacted ‘spitting mad’, as HCA commercial director Keith Biddlestone

puts it. Everyone at HCA was furious. He says: ‘It feels as if we are being asked which of our children we should put up for adoption.’

But they won’t talk about that now. Everyone is concentrating on the next step. ‘We will appeal; we will fight it; we will get independent judges and we are very optimistic we will win.’

cost millions

So far, the competition inquiry has cost countless millions of pounds to those called to give account. Mr Biddlestone reckons HCA alone has already spent £8m and expects the appeals tribunal will cost £2m.

‘Everyone would far sooner spend the money on patient care,’ he says. ‘You look around the industry and add up the numbers – it’s staggering.’

And all to come up with what the hospital group sees as a flawed analysis. Repeatedly at each stage of the inquiry, they have had to climb down, Mr Biddlestone says.

‘We think that’s a reflection of the poor quality of the analysis and so it does not provide a firm basis on which to require divesture.’

HCA thinks divesture is incredibly aggressive. There is just one precedent for this in the UK – the British Airports Authority had to sell Gatwick, Stanstead and Edinburgh airports ‘to correct a botched Government privatisation’.

From 2 April, HCA had 60 days to lodge its appeal to the competi-

tion appeals tribunal. A three-day hearing is envisaged between autumn and Christmas with a decision in February-March 2015. It could run and run.

Subsequent appeal stages could take it to the Court of Appeal and the European Court of Justice.

Mr Biddlestone maintains the end result will not transform the private healthcare industry. If the competition body’s case is successful, it will reduce prices by £9.5m a year in an industry turning over £6bn, he says.

Meanwhile, it is business as usual as the group focuses on the appeal. Consultants are nervous about any changes but are being assured HCA will ‘fight every step of the way’ to win.

siege mentality

At the moment, there’s a siege mentality. ‘The consultants are coming together with us and know they can rely on us. We will continue to run the hospitals and invest in kit. We spend £40m-£60m a year on making sure our hospitals are the best. We are not going to pause for a moment on this. Any competitor who thought we’d ease up on this will be disappointed.’

Asked why HCA has been going ahead with expanding London Bridge Hospital into three floors of The Shard, when it knew it

It feels as if we are being asked which of our children we should put up for adoption

might have to divest the hospital, he responds: ‘It was business as usual. We took some space at The Shard and were confident we’d find someone in the commission that agreed with us. We signed a contract for spending on The Shard. That goes on.

‘Consumers will continue to walk past some of the alternatives in order to come to our hospitals because they know they are so good,’ he says. And patients from overseas – responsible for a quarter of its revenue – ‘will continue flying past hundreds of hospitals’ to get to HCA facilities here.

He says that, 13 years ago, HCA acquired some hospitals in a merger which was cleared by the Office of Fair Trading. They were then not the best hospitals in the world. But now they compete well with hospitals around the globe. What is proposed is ‘bad for patients, bad for London and bad for the economy’.

One thing HCA does agree about is that every hospital should disclose clinical outcomes. Mr Biddlestone says that is the best thing to come from the review.

Ironically, if it is forced to sell, the divestment could happen before the data is available that might yet show these hospitals –and their consultants – are getting the best results in the UK. 

PRoTEcTing PATiEnT dATA

Destroying data for

Simon Walsh explains why and how it is so important to dispose of IT and telecommunications equipment safely and sustainably

The DaTa Protection act 1998 is probably one of the mostly commonly referenced pieces of UK legislation – but that does not mean that it is commonly understood.

In the healthcare sector, the issue of patient confidentiality is a universally accepted duty of care, but, with the advent of technology, those moral and legal obligations to safeguard information go far beyond the secure filing and shredding of paper files.

Secure hosting and adequate disposal of computer files, email correspondence, SMS messages and phone records is essential, not just for compliance but to ensure patient protection.

The rules relating to the handling of individuals’ personal data are not only encased in law, they are also vigilantly policed by the Information Commission ers’ Office (ICO), and any failures to protect data can – and often do –result in onerous fines, usually reaching five-figure sums.

Those responsibilities are the same whether the information is held securely onsite or moved to another location.

So, when it comes to information held on computer systems or mobile phones, data security is a much more complex management issue than it was during the days of paper-only records.

When computer hardware or mobile phone handsets are replaced, deleting files or transferring them across to the new system may not remove all the data embedded in the old hardware, potentially leading to breaches in Data Protection act compliance.

Useful guidance

Both the GMC and the BMa have issued a guidance document for doctors on confidentiality, and the guidance is the same for independent practitioners as it is for NhS doctors.

h owever, scant mention is made of the data protection implications of disposing of redundant IT and mobile phone hardware.

The BMa Confidentiality Toolkit simply states that ‘electronic data should be destroyed using appropriate data destruction software’.

Both guides do signpost professionals to the Department of health’s Information Governance Toolkit, which has a ‘Secure Disposal or Re-use of equipment’ section, outlining obligations and discussing best practice.

This guidance clearly states that equipment must not be passed on or re-used without first ensuring that all sensitive or confidential data has been ‘irrevocably destroyed’. It also cautions that a full record of the devices/drives erased and the destruction method used must be kept by any third party contracted to provide the service.

While this advice is useful, it does not fully explain a best practice approach to secure data erasure when disposing of redundant IT equipment or mobile phone handsets.

Nor does it reiterate clearly enough that the responsibility for ensuring there is a fully accountable audit trail for every item of equipment remains with the healthcare provider.

Doctors must understand that they remain responsible for maintaining data security even if their data erasure obligations have been outsourced

for good

Expensive errors

The salutory example of N h S Surrey’s arraignment last summer provides a cautionary tale. While the health authority ostensibly did everything right by employing a third-party ‘specialist’ to destroy its data and dispose of the hardware, its cost-saving approach left the authority exposed to data protection failings.

The data destruction company had offered a ‘free’ service in return for the right to sell on the equipment, which was then sold on eBay with thousands of patient records still accessible on the hard drives. The result was a £200,000 fine and legal proceedings.

In the N h S Surrey case, the third-party company’s promises to destroy the hard disks using an industrial guillotine were simply not fulfilled, but the health authority was culpable because it had not monitored the process or gained the required proof that the data had been destroyed.

There is a lesson here for any doctor or healthcare provider when it comes to understanding their obligations and applying due diligence in selecting a disposal supplier.

h ealthcare practitioners must understand that they remain responsible for maintaining data security even if their data erasure

HoW to enSure Data eraSure comPliance

1 refer to the ‘Secure Disposal or re-use of`equipment’ section of the Department of Health’s information Governance toolkit

2 ensure that the importance of data security is communicated effectively throughout your practice and that all redundant equipment is accounted for with a centrally co-ordinated policy

3 only use a secure data erasure specialist that is a certified user and gold partner of Blancco software and an aDiSa member

4 Demand a fully accountable audit trail for every device or drive

5 look for a supplier that will transport your equipment in its own vehicles to remove any risk of data loss while in transit

obligations have been outsourced and they must choose a partner with a proven track record of accountable service.

Proven partners

The good news is that there are some very simple checks that healthcare practitioners can use to verify that the data erasure specialist they work with will ensure they remain fully compliant.

Selecting an asset Disposal and Information Security a lliance ( a DIS a ) member will provide a guarantee of best practice and secure data erasure expertise.

The organisation is a group of leading experts in risk management, compliance and data protection and it demands high standards of data sanitisation from its members, who must achieve a minimum score from a stringent assessment in order to gain accreditation.

ensuring that the data erasure specialist is a certified user and gold partner of Blancco data erasure software also guarantees maximum levels of security, and doctors should expect full account management and detailed reporting for every item of hardware.

Finally, the healthcare business remains accountable for any lapse in data security while the IT or mobile phone equipment is in transit, so it is also advisable to look for a supplier that will collect everything in their own unmarked vehicles to remove the risk of items going missing with a third-party courier and also ensure complete accountability throughout the process.

due diligence

e lectronic patient records have made the process of record keeping easier and more efficient for all healthcare businesses, but that ease of use comes with a management obligation that does not end when the IT hardware is no longer in use.

Understanding those obligations is an important ‘due diligence’ issue and addressing them with accountable third-party expertise is the only way to ensure compliance. 

Simon Walsh is co-founder of secure data erasure specialist ShP Ltd

Billing FoR yoUR woRk

A complex code to crack

Billing errors are costing consultants’ private practices a fortune and when you consider the complexities involved, it is no wonder, says Garry Chapman

We have been billing for consultants for 22 years and I still visit practices where it is not being done as well as it could be.

While this is disappointing, it is not surprising considering the changes that have occurred over the past few years and that continue to happen on a monthly basis.

Most practices I see are extremely busy, with both the consultant and the secretary being stretched on a daily basis with the workload they have to deal with.

Consultants are typically running both an NhS practice as well as a private practice, which means that they have very little spare time, especially if they are trying to juggle family commitments on top of this.

Secretaries will be organising the clinics and theatres, dealing with the patients, the letters, the phone calls and the emails on a daily basis. On top of this, they are raising the invoices, reconciling the payments and chasing the shortfalls. They have very little spare time, if any.

The question of who is making sure that the billing is being done correctly is therefore a difficult one to answer. But if the practice does not want to lose money on a continual basis – or worse, fall foul of the insurance company regulations and risk being derecognised by them – then they

need to make plans to address this critical area.

The main components involved in this area are highlighted below. It is vital for the practice to understand how complex and important this issue is in order to determine what steps to take.

CCSD

CCSD stands for Clinical Coding and Schedule Development group and it was formed by five major private medical insurers in 1997.

Bupa, a X a PPP, aviva, Simply health and Pru health were the insurers involved at the beginning and, to this day, they still have representation on the board.

The original scope involved two projects. The first was the development of revised medical codes and associated narratives and the second was the development of setting a scale of relative values for the codes, depending upon the complexity.

however, after an Office of Fair Trading investigation, it suggested that the second development project should not progress and that decision is one of the main reasons why today the difference in value per CCSD can be up to 100%, depending on the specialty and the insurance firm. after long correspondence and discussion with consultants across 22 specialties, the CCSD schedule was launched in 2006. It

has progressed since then and now comprises of more than 2,000 codes.

In September 2013, it also launched a schedule for diagnostic codes. an important point to note is that the CCSD schedule is updated on a monthly basis and can include any of the following:  Rules on which codes can be billed together and those which cannot – commonly referred to as ‘unbundling’;

 The narrative against a specific code;

 Replacement codes;

 Discontinued codes;

 New codes.

any of the above could have an impact on the way that the practice does its billing. Unless the schedule is checked each month for updates to establish if they affect the practice, then you could be billing with errors.

insurers’ variations

The CCSD schedule is used as the sole platform for coding for private healthcare and the private medical insurers use it as a basis to create their own fee schedule. This is complicated by the fact that the insurers do not have to use the CCSD schedule rules, as it is not mandatory.

This means that each insurer can choose to adopt the CCSD schedule in whole or part, resulting in the fact that some insurers

do not recognise specific codes and some insurers have their own rules on which code combinations are acceptable for billing purposes.

I have listed some of the main exceptions below:

a particular insurer will allow an aC100 (local anaesthetic) to be billed with a selected list of minor codes, but it does not publish a list; a particular insurer will only allow certain codes to be billed in conjunction with a follow-up consultation; a particular insurer will not allow a follow-up consultation to be billed within ten days of an operation;

a particular insurer will restrict the amount of inpatient care that can be billed by including a set amount within the specific code used in surgery. Due to the above, there are many varied and complex rules that exist regarding the use of the codes and, on top of this, you need to understand the pricing structure relative to each insurer. here are some of the main variables that currently exist:

Some insurers have a fee for each CCSD code;

Some insurers place each CCSD code into different categories for pricing purposes;

Some insurers do not publish a schedule – they will pay what they consider to be market rate.

Formulas for multiple codes

Once you have understood all of the above, then the final piece of the jigsaw is to understand the formula that can be applied for each insurer, dependent upon the number of codes used.

See some examples below:

Example 1

 Some insurers will state that if you bill three codes together, then you multiply the highest value code by 40% and then add that figure to the price of the highest value code.

 Some insurers will state that when two codes are used, you multiply the price of the highest value code by 25% and then add that figure to the highest value code.

Example 2

 Some insurers will state that if you bill three codes together, you take the highest value code and add to that 50% of the second highest

value code; then add 25% of the lowest value code to the figure that you have already calculated.

 Some insurers will state that when two codes are used, you add 50% of the second highest value code to the price of the highest value code .

Example 3

 Some insurers will state that when three codes are used, you can only charge for two codes, as they do not recognise the use of three codes.

 Some insurers will state that when two codes are used, you add 50% of the second highest value code to the price of the highest value code.

Summary

We are not surprised when we visit practices where the billing is not being done correctly, as it is a full-time job to keep abreast of all of the rules as well as all the

changes that take place on a monthly basis.

On top of this, the practice has to keep abreast of any price changes that occur. These can be up as well as down; so, again, it is vital to ensure that all of these areas are monitored closely.

The most common errors we see are pricing-related. This is where the wrong price is chosen due to either wrong use of codes or where the wrong formula is used or where the wrong price is used for a specific code for a specific insurer.

The worst part about this is that, in many cases, it has been going on for years, so the loss of revenue over that period can be dramatic.

what should you do?

❶ Understand the complexities of the CCSD schedule for your specialty, including what coding combinations can be used;

❷ Make sure that you code correctly by understanding the nar-

rative for each code and checking each month to make sure that it has not been discontinued or replaced by a new code; ❸ ensure that you know the formula used by each insurer for pricing multiple codes; ❹ Be aware of the different rules each insurer will have over and above the CCSD schedule.

Maintaining all of the above is an almost impossible task for one person to cope with. In our experience, as the practice continues to grow, the consultant and the secretary are so busy dealing with the medical side of the practice that billing is frequently neglected.

If you are struggling doing all of the above, then you need to consider outsourcing your medical billing and collection, as this specialist knowledge will typically form part of the service. 

Garry Chapman is managing director at Medical Billing and Collection

The threat of

Long-term house price rises could be costly for many of the big proportion of independent practitioners who have a home in the South-east or London. Dr Mark Martin (right) explains why your ordinary family home could get caught by a proposed ‘wealth tax’

If your property was purchased over a decade ago, you have probably enjoyed watching the value of your house rise. yet further increases may not be as welcome if a new ‘mansion tax’ is introduced, taking many ‘ordinary’ houses in the South over the threshold.

The idea of a ‘mansion tax’ has been used as a political football for several years, but has reemerged amid the jostling ahead of the next general election.

Championed originally by the Liberal Democrats, the premise is that any home worth more than £2m would be taxed at an annual rate of one per cent of its value above the threshold in order to bring in tax revenues of £1.7bn.

The tax would be levied overwhelmingly on London and the south-east of England, where eight out of ten of £2m-plus homes are based.

Ed Milliband has also embraced the concept, but wants to raise £2bn, stating that the previous ‘trickle down’ approach to wealth distribution had failed. ‘We would use the money to cut the taxes for working people,’ he announced.

poor calculations

A recent report from property group Knight f rank, however, suggests both parties have considerably underestimated the number of homes that would have to pay the tax.

It found that in order to raise the target revenue, the value threshold for the properties would need to be reduced from £2m to £1.25m. This would more than double the number of properties affected from 55,000 to 140,000.

Even if the threshold is not lowered, there is always the possibility – given that the £2m figure has been quoted since 2009 – that it would not be raised in line with future house price inflation. The threshold would then be so low that many flats in London and ordinary family homes in the South-east would be caught. As it stands, 10% of properties in London valued at over £2m are in fact one- or two-bedroom flats. o ver the past ten years, property prices have risen by 69%. Assuming a similar rate of growth in the future, all houses worth

Many homeowners will have much of their wealth tied up in their property and would struggle to pay anything like the £2,000-a-month average mansion tax

because they have a fabulous income and lots of disposable capital, but because they are people who bought homes maybe 20 or 30 years ago for a fraction of what they are worth now. They are people maybe becoming elderly who are asset-rich and income-poor.’

Therein rests the real problem. Data shows that almost one third of all properties worth over £2m have been in the same ownership for ten years.

Many of the homeowners will have much of their wealth tied up in their property and would struggle to pay anything like the £2,000-a-month average mansion tax. And they will have to keep paying it, year after year; no matter if the individual stops working or their income falls.

Some would suggest they should sell up and move on, but is it fairer that a wealthier investor, perhaps an overseas buyer, moves in?

Property investors could also be left almost entirely unscathed, even amassing properties whose real market value was in excess of £2m, but which were now being sold for less thanks to the effect of the new levy.

Costly administration

The tax would also not take account of the size of the mortgage on a property, making it difficult for people who have borrowed large sums of money on their dream home.

As for the properties themselves, can we assume there will be an incentive to down-value houses to neglect or limit their value? Perhaps lofts will no longer be extended, garages no longer converted.

Critics recall windows being boarded up – the original daylight robbery – during the window tax of the 18th and 19th centuries.

What’s the alternative?

The most accepted suggestion is to revalue the current bands of council tax. At present, in England it is levied in eight bands, with the highest band for property valued over £320,000 based on outdated 1991 prices.

It is an unlikely vote winner; the u K already has one of the highest property taxes (as a proportion of GDP) among industrial countries.

other European countries have abolished their own ‘wealth’ taxes in recent years. Sweden put an end to its wealth tax in 2011 because it raised only £400m a year but kept over £140bn of Swedish-owned capital outside the country.

The french on-again off-again 75% tax on the wealthy has been cited as the main cause of tax exile, fuelled in part by the publicity surrounding the departure of actor Gerard Depardieu.

more than £1.2m today would be paying a mansion tax ten years from now, tripling the number of homes affected to 157,300. over the next 25 years, the number of properties impacted by the tax would increase to 775,500.

While the Conservatives are not in favour of the proposals, who knows what deals might be struck to renew the existing coalition?

Winners and losers

The opposition is not entirely in favour either. Dame Tessa Jowell, one of the figures tipped to run as London Mayor, said: ‘I represent a constituency where it would be an issue for some people. Not

Is the value of a property – simply a calculation of what someone is prepared to pay for it – really an accurate measure of a person’s wealth? If an individual has a property worth around £4m, are they wealthier than the next person who owns two properties, each valued around the £2m mark?

A mansion tax would require an expensive valuation exercise to be carried out, possibly in tandem with revisiting council tax bands.

And as soon as the tax is introduced, the value of the property will change. In America, where property taxes are common, homeowners have challenged valuations they do not agree with, especially those teetering around the threshold, leading to costly judicial reviews.

Whether a mansion tax is ever established in the uK remains to be seen. We can be certain we have a year ahead of political rhetoric on the subject.

Let us hope whoever is in charge in the future gets the sums right.

Denis Healey, Labour’s Chancellor of the Exchequer in the 1970s, once stated that you should never commit yourself in opposition to new taxes unless you have a very good idea how they will operate in practice.

He said: ‘We had committed ourselves to a wealth tax: but in five years I found it impossible to draft one which would yield enough revenue to be worth the administrative cost and political hassle.’

Dr Mark Martin is chairman of Cavendish Medical, specialist financial planners helping senior consultants in private practice and the NHS

Ways of avoiding the tribulations of tribunals

Too many doctors who employ staff have got into time-consuming – and very expensive – trouble with tribunals over the years. Chris Inson gives some smart advice on avoiding tribunal claims

The decision to dismiss an employee will often be a difficult one; whether by reason of redundancy, poor performance or some other reason.

however, the aftermath of dismissal, including the potential for employment Tribunal claims, can cause more problems and detract from your focus on managing your practice.

Redundancy

Redundancy can arise as a result of a number of circumstances. it may be that you have to close your practice or, more likely, have a reduced requirement for employees completing a particular role.

Whatever the reason for potential redundancies, it is essential that you conduct a fair redundancy procedure.

This will include identifying the roles and employees who are at risk of redundancy, consulting

with those at risk and making the final selection based on objective criteria. Remember that collective consultation with a trade union or employee representatives is required for 20+ redundancies. You should also consider whether there are any suitable alternative roles within the practice for any employees who will be made redundant.

At all stages of a redundancy process, you should consider whether there is any way to avoid compulsory redundancies, such as reducing the use of agency workers or contractors, retaining employees on reduced hours or inviting staff to apply for voluntary redundancy.

if an employee dismissed by reason of redundancy has two years’ service, they will be entitled to a redundancy payment.

The statutory redundancy payment is calculated with reference to the employee’s gross weekly

When you decide to dismiss, you must invite the employee to a formal hearing

pay, their age and their length of service and can be in excess of £13,000. A contractual redundancy policy may be even more costly to your practice.

performance management

i t can be extremely difficult to operate a successful practice when one or more of your team is under­performing.

Performance management is essential to ensure the required performance levels and, in turn, morale within the practice. c onversely, a failure to address poor performance at an early stage could have undesirable effects for the surgery.

You should ensure that your employees understand the standards expected of them. This should be made clear at the outset and then, if required, at the start of a performance management process.

i n addition, a probationary

period at the beginning of employment or following a promotion allows you to assess the employee’s suitability for the role.

A well­utilised appraisal system provides you with both the opportunity to gauge an employee’s continued standard of performance and valuable evidence in the event that it becomes necessary to begin a capability process.

h owever, it is important to avoid taking a heavy ­ handed approach and to consider whether there are any underlying reasons for poor performance. A failure to do so may lead to a claim for constructive unfair dismissal or may even amount to discrimination if, for example, the reason for poor performance is an underlying disability or child care issue.

There will inevitably be cases where performance management will not bring about the desired result. should you choose to dis­

miss, capability is a potentially fair reason for dismissal.

This means that if you conduct a fair procedure when dismissing an employee for poor performance, it is unlikely that a claim for unfair dismissal will succeed.

For a fair dismissal on the grounds of capability, you must reasonably believe the employee to be incapable.

This belief will be demonstrated by conducting a reasonable investigation and a formal poor performance hearing, where your concerns are made clear to the employee with reference to training records and performance appraisals and a written warning should be issued.

You ought to allow an underperforming employee a reasonable opportunity to improve. You should offer reasonable support and/or training to the employee and must continue to review their progress.

You ought to allow an underperforming employee a reasonable opportunity to improve

By displaying that concerns were raised, and that the employee failed to heed warnings, any dismissal on capability grounds is significantly more likely to be ‘fair’.

When you decide to dismiss, you must invite the employee to a formal hearing.

You may consider whether there are any other possible roles within the practice, particularly if the poor performance has followed a promotion.

Please be aware that it is unlikely that one incidence of poor performance will be sufficient to justify a fair dismissal. There is also the potential for performance to lapse following completion of a warning period. if this occurs repeatedly, it may be reasonable to impose an increased warning period or, in extreme cases, deal with the underperformance as a misconduct issue.

Avoiding tribunal claims

There are a number of potential claims which may arise from a dismissal, including wrongful dismissal, unfair dismissal, discrimination, unlawful deductions from wages. i will focus here on wrongful dismissal and unfair dismissal.

Wrongful dismissal occurs where an employer dismisses an employee without notice in a situation where they were not entitled to do so – that is to say, where the employee was not guilty of gross misconduct.

it is unlikely that summary dismissal will be justified where dismissal occurs as a result of an employee’s poor performance. i n order to avoid a claim for wrongful dismissal, your employ ee should be given notice (statutory or contractual) or paid in lieu of notice if their contract provides for this. For the avoidance of doubt, statutory minimum notice is one week for each

full year’s service up to 12 weeks. i n most cases, new starters beginning after 6 April 2012 must have worked for an employer for two years before they are able to bring a claim for unfair dismissal. e mployees whose employment began before this only require one year’s service.

it is worth noting that there are some dismissals for which no service requirement exists – for example, if the employee is dismissed for ‘whistle­blowing’ or on discriminatory grounds. i f the employee has the required service, an employer must show that they have a fair reason for dismissing.

As explained above, one potentially fair reason is capability or qualification. The other four potentially fair reasons are conduct, redundancy, illegality and ‘some other substantial reason’.

After establishing the fair reason for dismissal, you must follow a

fair procedure when dismissing. if dismissal is for conduct or capability, this will require following the AcAs code of Practice on disciplinary and Grievance Procedures. Where dismissal is for another reason, a fair procedure will include as a minimum:

 Giving the employee information regarding the reasons for the possible dismissal;

 Allowing time to prepare a ‘defence’;

 Permitting the opportunity to respond at the hearing;

 Providing written reasons for dismissal;

 Providing employees with the right of appeal.

since 29 July last year, employers and employees have been able to enter into pre ­ termination negotiations, prior to a dispute arising, without the risk of such negotiations being used as the basis for a claim for constructive unfair dismissal.

There is no guaranteed way of preventing an employee bringing a claim against you following dismissal

it may be commercially preferable for the practice to reach a financial settlement for exit, rather than going through a disciplinary/capability procedure and the risk of tribunal proceedings. h owever, such negotiations are only inadmissible in relation to ordinary unfair dismissal claims –i.e. not discrimination – and where there has been no ‘improper behaviour’.

in summary

There is no guaranteed way of preventing an employee bringing a claim against you following dismissal. h owever, ensuring that you follow a fair and consistent procedure and retain records at each stage of the process will reduce the likelihood both of employees bringing claims and of any claim being successful. 

Chris Inson (left) is a partner in the Healthcare Team at Capital Law LLP

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Volunteers still need

Dilemma 1

Am I covered to aid charity run?

QI am a consultant physician working in independent practice. There is a charity sports event taking place in my village and I have been asked if I would volunteer to provide medical support on the day.

As it is for charity, I would like to take part – but, before agreeing, I want to make sure I am indemnified for any treatment and care I might provide.

AIt is always important to make sure you are indemnified for any clinical work you do, regardless of whether it is voluntary or paid. In fact, doctors have an ethical requirement to ensure they have adequate insurance or indemnity (GMC, Good medical practice [2013], paragraph 63).

In its publication Insurance and indemnity: guidance for doctors, the GMC offers specific advice for doctors who wish to volunteer to provide medical assistance at an event.

It says: ‘Doctors who perform such acts are providing professional services irrespective of whether they are paid or unpaid.

A

doctor’s query about indemnity insurance for his voluntary medical services at a charity fund-raising event kicks off this month’s eclectic selection of ethical posers.

Dr Sally Old (first right) and Dr Shelagh Turvill (far right) provide the answers

‘If indemnity is not provided by the organisation for which you are providing this service, you will need to make your own arrangements to ensure you are adequately indemnified against any claims that might arise from this work.

‘You should contact your medical defence organisation to advise them of your role and to discuss whether you have or need suitable professional indemnity or insurance cover.

‘In order to enable them to make this judgement, you must provide them with accurate and up-to-date information about the scope and nature of the work.’

It is your responsibility to check beforehand if the event’s organising body provides indemnity for

doctors acting in a professional capacity.

If they do not, it is important to check with your medical defence organisation to make sure that your current membership will indemnify you for the voluntary work you plan to do.

Whatever event you are helping out at, it is important to ensure that you have the appropriate skills, experience, equipment and support, and that you do not practise outside of your area of expertise.

The GMC states that you must recognise and work within the limits of your competency (GMC, Good medical practice [2013], paragraph 14). As with any care you provide, you should keep detailed records.

Dilemma 2 Can I give notes to absent dad?

QI am a consultant dermatologist with my own private practice. I have been treating a 14-year-old patient who has always been brought to her appointments by her mother.

However, today I received a written request from her father requesting his daughter’s medical records. I understand that he is estranged from the child’s mother. What should I do?

AThe issue of disclosing a child’s medical records is a tricky one. Firstly, a doctor must establish whether a parent has parental responsibility. The GMC’s 0-18 years guidance (2007) explains that parental responsibility relates to the rights and duties that parents and guardians have by law for their child, and is defined in the Children Act 1989. Generally, married mothers and fathers both have parental responsibility unless this has been removed by the court. Under the Data Protection Act 1998, a person with parental responsibility has a right to apply for access to their child’s health records.

insurance ...cuts into lost fees!

However, as the child is 14 years old, you may wish to consider whether she has capacity and, if so, you may wish to involve her in the decision to allow her father to see her medical records.

In determining whether to disclose records, you should also consider whether it is in the best interests of the child, even if the child has consented, particularly if there is any sensitive information about the father within the notes.

The records should also be checked to ensure that disclosure of all or part of them would not cause serious harm to the physical or mental health of the child or any other person.

You should also ensure that there is no information within the medical records about third parties. In general, this should not be disclosed without appropriate consent being obtained first.

Dilemma 3 I supect female circumcision

QI am a GP working in private practice. I have been treating a young teenage patient for the last three months.

She has confided in me that her parents want her to travel abroad in the school holidays with the intention that she will be circumcised. I know this is illegal, but it is a sensitive issue and I am not sure what the best response will be to help my patient.

AFemale genital mutilation (FGM) – sometimes known as female circumcision – has been illegal to carry out on a resident of the UK since 2004, regardless of

whether the act is committed in this country or abroad.

It is a difficult topic, which should be addressed sensitively under child protection procedures, with the best interests of the child considered above those of the parents or carers.

Doctors are advised to ‘identify girls who are at risk of female genital mutilation as early as possible and refer suspected cases’ to children’s services as part of their child protection procedures.

Practitioners have an obligation to report and refer cases where they suspect a child is likely to suffer or is suffering from ‘significant harm’ and have an ongoing ethical duty to act on any concerns that a child may be at risk.

The GMC states that ‘female genital mutilation . . . is a serious crime and a child protection issue’.

In cases where FGM is suspected, doctors are advised that the child’s best interests should take precedence over those of the parents or carers. Doctors would be justified in reporting their honestly-held suspicions, as long as they take action through the appropriate channels.

Consent should usually be sought to share information unless there is a compelling reason not to do so; for example, if it would put the child at further risk.

It is a good idea to discuss concerns with a more experienced colleague or child protection adviser or with an MDU adviser. 

Dr Sally Old and Dr Shelagh Turvill are medico-legal advisers at the Medical Defence Union

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sTARTing A pRivATE pRAcTicE: yoUR qUEsTions on TAx

Your new horizons

Following Independent Practitioner Today’s news last month of record numbers of new independent practitioners – NIPs – entering private practice, Ian Tongue tackles the common questions doctors are asking when starting out

? ? ?

confounded by tax

For most doctors, their training offers little by way of financial advice and that inevitably makes taking the step towards engaging in private practice more daunting. When starting out in private practice, or in the early stages, independent practitioners will have many financial questions.

t hey are not alone in raising these questions and, while not exhaustive, the questions covered here are some of the more common ones that I get asked.

qHow does the tax system work?

For most doctors, their tax has historically been collected under the Pay As You Earn (PAYE) system and, on the whole, it works for basic circumstances.

However, during training, you often move between hospitals and it is important that you keep an eye on your tax code, as significant variations can arise.

t he self-assessment system is there for those with more complicated affairs or earnings in excess of £100,000 and other circumstances.

the system requires registration and it is always suggested that you engage an accountant to assist you with tax compliance. Under self-assessment, you have to submit a tax return to Hm revenue and Customs (HmrC) each year by 31 January following the tax year in question for electronic submission, and a shorter 31 o ctober deadline is in place for paper copies.

Payments under self-assessment are made in January and usually July each year. You are taxed in arrears, but usually have to make a payment on account, which can often catch people out, particularly if you have experienced rapid growth in earnings.

qWhat is an HMRc inquiry?

s elf-assessment is just that. You supply a summary of your tax position from all sources and very little else by way of supporting records and information.

t he inquiry system is how

H mr C police things. At some point, you probably will get an inquiry of some sort and it is usually nothing to worry about.

HmrC does not release specific criteria for selection, but is it is likely that you will be selected if:

 An income or expense has a significant unexpected variation;

 You have not provided all information to your accountant;

 You have entered into a tax avoidance scheme or aggressive tax planning.

It is important to note that the fees charged to complete your tax return do not normally cover any inquiry that may arise on the figures. most accountants offer an insurance policy to cover against the costs of dealing with an inquiry.

qWhat records do i need to keep?

HmrC has the powers to fine you if you do not keep adequate records. While there is no real definition of this, it practically means that the figures are complete, accurate and up to date.

When starting out, your accountant should provide you with some pointers on recordkeeping, but the key thing is to have a robust system and avoid mixing your business with personal finances.

most people starting out adopt some form of spreadsheet to record income and expenditure and basic filters can assist in sorting the data – for example, to work out who has not paid yet!

➱ p48

PaymenTs on accounT

QWhen will my first tax liability arise?

This is usually the first January after the tax year in which your circumstances changed.

For example, someone commencing trade as a sole trader on 1 June 2013 would have a first period of 1 June 2013–5 april 2014 to account for. The tax on these earnings would be due by 31 January 2015.

To put some basic numbers to the above, if your tax liability for the year ended 5 april 2014 was £10,000, this would be payable by 31 January 2015.

at that level, it is likely that a payment on account would also be due in January 2015 for the 2014-15 tax year (year ended 5 april 2015).

This is set at 50% of the previous year’s liability by default. Where payments on account are required, a second payment is required by 31 July.

again using the numbers above, the payment in January 2015 would become £15,000, representing £10,000 for the year ended 5 april 2014 plus £5,000 as the first payment on account for 2014-15.

In this example, a second payment on account of £5,000 is required by 31 July 2015.

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q

Do i need a computerised accounting package?

When volumes of work are modest, simple records are usually sufficient.

But a practice of any significant size is likely to benefit from a practice management system, most of which have the dual benefit of assisting in the running of the practice as well as maintaining the finances.

q How does indemnity insurance work?

one of the first questions you will be asked is your projected income. this can be a difficult question to answer – but just be realistic.

the composition of income is important, as some work may be covered by the NHs indemnity or other body and work such as medico-legal work is treated differently.

If you can see early on that your estimate was out, particularly if understated, it is important to contact your defence body. they come across this regularly and usually you simply pay the extra premium due.

one complication can be that your indemnity cover year may not run to the same period as your financial year. However, your accountant should be able to assist you in this area.

q should i be a company?

a practice of any significant size is likely to benefit from a practice management system

Fill in the direct debit form on page26 and post it to: Independent Practitioner Today subscriptions department, Promotion 134104, FReePosT, Po Box 36, Plymouth PL2 2BR

How to subscribe and we’ll also knock £15 off the usual £75 cost of our annual subscription of Independent Practitioner Today. But hurry – this offer is only valid for a limited period For any queries or advice, phone Lisa Richardson on 01752 312140 or email lisa@marketingcentre.co.uk or go to our website at www.independent-practitioner-today.co.uk

this is an article in its own right and there is no generic answer here. t his trading structure has become more popular in recent years and, for many, it can be a more tax-efficient structure. the key thing to ensure is that the company itself can be shown to be trading.

You should discuss your individual circumstances with your accountant who should understand your specific position and the medical profession in general.

qi’ve heard you can pay school fees and other personal expenses – e.g. family holidays – through a company. is this true?

As an employee, it is common to negotiate with your employer for a better ‘package’ of salary and benefits.

the rules around this are relevant for this question and the implications of providing these benefits must be considered from both the company and your personal perspective.

In many cases, it does not increase disposable income, could be questioned by H mr C and could actually cost you more. If your accountant is suggesting this, ask them to provide calculations on a disposable income basis and ensure that the risks are fully explained.

q

Do i need to be vAT registered?

t he answer to this is ‘possibly’. VAt is a tax that businesses collect rather than pay as such. s o it is the services that are provided that usually determine whether you need to register for VAt and charge VAt accordingly.

Where the service is principally aimed at the protection, maintenance and restoration of health of the person concerned, the supply is exempt from VAt.

t he most common areas that are standard-rated and form a taxable supply are medico-legal work and work purely for cosmetic or aesthetic reasons.

In relation to medico-legal work, this is standard-rated, as the principal reason for the work is to help a third party, such as a court, to arrive at a decision.

In relation to cosmetic/aesthetic work, this remains a grey area, as work can be undertaken for a variety of physical and psychological reasons and the location of treatment can have a bearing.

this is an area of on-going discussions, with HmrC and various bodies looking to reach some common ground on how this determination can be made.

Even if you are making taxable supplies, you do not need to register until those supplies exceed the VAt registration threshold, which is £79,000 on a 12-month rolling basis at the time writing.

qcan i get tax relief for using my private car? there has been a recent tax case,

well documented by Independent Practitioner Today (see particularly February 2014) involving a consultant whose circumstances provided consideration of exactly what is business-related travel for a doctor engaging in private work. Unfortunately, the case went against the taxpayer and the implications are likely to reduce

VaT is a tax that businesses collect rather than pay as such

the ability to claim for businessrelated travel to those journeys between private hospitals and business meeting.

It now seems there will be no further appeals to the tax courts on this matter.

the answer is therefore likely to be ‘yes’, but the claim in many cases will be modest. Your accountant will be able to discuss matters further with you.

the above is not exhaustive and the answer to each question may vary depending on circumstances, but it covers some of the more common questions that are topical.

As always, discuss your circumstances with an accountant who can advise you further.

 next month: pension annual allowance statements

Ian Tongue (left) is a partner with Sandison Easson & Co, specialist medical accountants

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King of the school run

Independent Practitioner Today’s motoring columnist Dr Tony Rimmer gets behind the wheel of Audi’s SUV – for doctors who want quality without turning too many heads

Like any private medical practice that has worked really hard to establish an excellent reputation for quality and up-to-date technology, a udi as a brand cannot afford to let standards slip.

e very new model needs to maintain its top-notch status. When it entered the SUV market with the large Q7 in 2005, it had produced a car that had excellent build but lacked individuality and very limited off-road abilities. experts predicted a failure.

However, the experts had got it wrong and audi had got it right. it knew that most large 4x4s never see anything more demanding than light snow and that buyers are more attracted by the high driving position and feeling of extra security.

These cars are kings of the posh school run. if you want to drive across fields, buy a Land Rover.

However, the Q7 is a big car,

more suited to the US market than our smaller roads in the Uk, so sales only really picked up when the smaller Q5 appeared.

Based loosely on the platform of the a 4 saloon, it competes directly with the BMW X3, the Range Rover evoque and Volvo’s XC90.

Soothing effect

as hard-working professionals, we appreciate excellent high-end products that improve our working and private lives. We reward ourselves with cars from the well-known makers of quality products.

There is a definite soothing effect to slipping behind the wheel of any audi at the end of a busy day, so is the Q5 any different from the others?

Originally launched in the Uk in 2009, it has recently been updated in subtle ways and is now

recognisable by distinctive L e D running lights. From a styling point of view, the Q5 could be nothing but an audi.

The design team has played safe rather than release a style icon like the Range Rover e voque. What it lacks in dramatic looks, it gains in practicality. Bigger and roomier than the small Range

Rover, it has the same passenger and luggage space as the BMW X3. Up to five passengers can be accommodated in great comfort. e ngine options include a 2.0 litre petrol in two states of tune, a 2.0 litre diesel in two states of tune and a range-topping 3.2 litre petrol V6 and a 3.0 litre turbodiesel V6.

Stick to the diesels for decent fuel consumption and the pick of the range is the fabulous 3.0 litre diesel that was fitted to my test car. Mighty and seemingly endless torque has a silky smooth and quiet delivery.

Impressive performance

Performance is in Golf GTi territory if pushed hard. For a big car this is very impressive, especially since it is still able to return up to 47.1 mpg at the pumps. a firm ride has always been an audi trait, but recent models have improved considerably and this updated Q5 is no different.

Long distances can be tackled in great comfort. Standard equipment levels are equal to competitors and you have to restrain yourself from adding too many intriguing but pricey options.

One feature i enjoyed was the radar-controlled cruise control. it was a boon on our busy motorways, where it is impossible to maintain a single speed for any length of time.

The radar detects a slower car ahead and retards the Q5 appropriately and then returns to the chosen cruise when the obstruction disappears. Magic.

Handling is very saloon-like and although there are sensors front and rear, parking can be a little challenging, as the car feels

really quite big from the driving seat.

although off-roading is not the a udi’s forte, it does offer hill descent control and excellent traction from the Quattro system.

So is this a car to recommend to medical colleagues? The Q5 is a high-quality, comfortable and practical, all-season family car, which, when fitted with the punchy V6 diesel engine, can give the keen driver some dynamic interest.

i t has a contemporary chassis that will form a base for the newest Porsche SUV, the Macan; a car that is the same size as the Q5 but more sporty and more expensive.

Praise indeed. Just don’t expect this audi to turn too many heads on the High Street. 

Dr Tony Rimmer is a GP practising in Guildford, Surrey

AuDi Q5

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Standard equipment levels on the Audi Q5 are equal to the competitors

ProfiTs focus: urologisTs

A big drop in earnings

Income, expenses and profits for urologists have all taken a dive in our latest unique benchmarking analysis of accounts. Our regular accountants Ray Stanbridge and Martin Murray report

Urologists have been going through a host of working changes.

some have become members of groups and that has tended to give them an income stimulus. others have incorporated, some have chosen to spend more time on ‘Choose and Book’ work – with possible reductions in indemnity costs – and yet others have chosen to try to add value to their practices by doing more diagnostic and other tests.

so the position becomes more complex in this specialty as each year passes.

Notwithstanding what is now becoming an ever increasingly long list of caveats, our headline figures are that the average urologist’s private practice income has fallen by 9% between 2011 and 2012 from £116,000 to £109,000.

We estimate that costs have reduced slightly by 2.6%, from £38,000 to £37,000. a s a result,

aveRage iNCoMe aND eXPeNDituRe oF a CoNSultaNt uRologiSt With aN eStaBliSheD PRivate PRaCtiCe

there also seems to be signs that the insurance company squeeze on some consultants’ fees has started to bite

taxable profits have fallen by 7.6% from £78,000 to £72,000. the headline reduction in gross fees seems to have been the result of two main factors. Firstly, and particularly in the provinces, consultants have been undertaking more ‘Choose and Book’ work. t his is perhaps not surprising with Nhs spend now exceeding 25% of the private market spend.

insurance company squeeze there also seems to be signs – recognising the limitations of our data – that the insurance company squeeze on some consultants’ fees has started to bite. We would expect these pressures to continue.

Costs, by and large, have been steady. there were slight decreases

Who ouR uRologiStS aRe

Expenditure

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

as in previous reports, our figures are based on a sample of consultant urologists who:

 have either an old-style or new-style NhS contract

 have been in private practice for at least five years

 have been earning at least £5,000 a year gross from private practice

 May be trading as a sole practitioner or member of a group  May or may not have incorporated

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in medical supplies/assistant costs and, surprisingly, room hire fees. t here were also reductions in bad debtors. t his is perhaps because many urologists have tightened up their debt collection procedures, often with the help of professional firms.

staff costs have shown a modest increase, perhaps mirroring the rise in tax-free personal allowances.

other expenses have also shown a modest increase – much of this is marketing/promotional spend.

PRoFitS FoCuS iS the iNDuStRy BeNChMaRK

Doctors and their specialist medical accountants use the statistics published in our ‘Profits Focus’ series to look at how their earnings compare with others and see where they can cut costs and boost their income.

Now all this information is available on our website and is free when you take out a subscription. either fill in the subscription form on page 26 or phone 01752 312140 or email lisa@marketingcentre.co.uk. get a discount by paying by direct debit. www.independentpractitioner-today.co.uk

Most other costs seem to have been stable over the year.

Possible upturn

looking ahead, on a broad view, there are signs that the market decline has bottomed out and there may be an upturn.

h owever, the impact of open referral systems, insurer’s price squeezes and the growth of Nhs business will, in our view, limit income growth.

We can expect to see some income shifts away from older,

towards younger consultants. the growth in indemnity costs seems to be stabilising, so the overall conclusion is for a ‘steady as she goes’ climate over the next year or so.

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

 Next month: Dermatologists and oncologists

How arE You DoiNg?

Use these benchmarking statistics to help you compare your financial performance with other specialists in private practice. Subscribers can check out their specialty in full at www.independentpractitioner-today.co.uk

ending 5 april

what’S coMing in MaY’S edition

Make sure you don’t miss our next issue, published on 22 May. only subscribers to the magazine are guaranteed to receive every copy and we don’t think anybody who is serious about continuing private practice in the future, when there is so much happening that will affect them, can afford to miss any issue.

Pay by direct debit using the subscription form in this issue on page 26 and we will give you your first three issues free and £15 off your subscription of £75. and you will be entered into a free draw to win the latest novel from anaesthetist-turned-writer Dr Quentin Smith (see page 6).

Coming up next month:

 the competition inquiry and you: we report on more of the implications for independent practitioners and the independent Doctors Federation gives some useful opinions and advice

 We will also be reporting from the BMa’s annual private practice committee conference, which has lined up key players to examine the Competition and Markets authority’s declared ‘remedies’ for the independent healthcare sector

 Private doctors and the Care Quality Commission’s regulatory fees: so are you getting a fair deal?

 Keep it legal – getting retirements right. Whether you have an outgoing partner leaving your medical practice or a new incoming partner, it is important to do it right

Published by The Independent Practitioner Ltd. Independent Practitioner

Today is editorially independent and thanks Bupa for its assistance with distribution.

Printed by Williams Press

Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

© The Independent Practitioner Ltd 2014

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

 Comicdoc! We meet Dr Kate hersov (pictured) who co-founded the world’s first medical education company for children. her business has produced over three million specially designed comic books so far to help kids in 50 countries understand their serious illnesses and health issues

 you and your finances post-Budget and this month’s tax relief changes

 expenses: could you be claiming back even more and cutting your tax bill?

 Creating a surgical clinic: the dream and the reality

 Pension annual allowance statements explained

 Profits Focus: dermatologists and oncologists

 Beeming beauty? our ‘Doctor on the Road’ drives the BMW X5

 Plus all the latest news and monthly features

aDveRtiSeRS: the deadline for booking advertising for our May issue is 26 april

eDitoRial iNQuiRieS

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Tel: 07909 997340

aDveRtiSiNg iNQuiRieS

Margaret Floate, advertising manager

Email: margifloate@btinternet.com Tel: 01483 824094

Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

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